Examining the Role of Family Physicians in the

Decision-Making Processes of

Canadian Medical Tourists

by

Rory Johnston

B.A., Simon Fraser University, 2010

Thesis Submitted in Partial Fulfillment

of the Requirements for the Degree of

Master of Arts

in the

Department of Geography

Faculty of Environment

Rory Johnston 2012

SIMON FRASER UNIVERSITY

Summer 2012

All rights reserved. However, in accordance with the Copyright Act of Canada, this work may

be reproduced, without authorization, under the conditions for “Fair Dealing.” Therefore, limited reproduction of this work for the

purposes of private study, research, criticism, review and news reporting is likely to be in accordance with the law, particularly if cited appropriately.

ii

Approval

Name: Rory Johnston

Degree: Master of Arts Geography

Title of Thesis: Examining the Role of Family Physicians in the Decision-Making Processes of Canadian Medical Tourists

Examining Committee:

Chair: Alison Gill, Professor, Department of Geography, SFU

Valorie Crooks Senior Supervisor Associate Professor, Department of Geography, SFU

Nadine Schuurman Supervisor Professor, Department of Geography, SFU

John Calvert External Examiner Associate Professor, Faculty of Health Sciences Simon Fraser University

Date Defended/Approved: July 31, 2012

iii

Partial Copyright Licence

Ethics Statement

The author, whose name appears on the title page of this work, has obtained, for the research described in this work, either:

a. human research ethics approval from the Simon Fraser University Office of Research Ethics,

or

b. advance approval of the animal care protocol from the University Animal Care Committee of Simon Fraser University;

or has conducted the research

c. as a co-investigator, collaborator or research assistant in a research project approved in advance,

or

d. as a member of a course approved in advance for minimal risk human research, by the Office of Research Ethics.

A copy of the approval letter has been filed at the Theses Office of the University Library at the time of submission of this thesis or project.

The original application for approval and letter of approval are filed with the relevant offices. Inquiries may be directed to those authorities.

Simon Fraser University Library Burnaby, British Columbia, Canada

update Spring 2010

iv

Abstract

Canadians are increasingly engaging in ‘medical tourism’. Medical tours mark a shift

from the gate-keeping model of care provision that underpins diagnostic and surgical

care in Canada, wherein family physicians refer patients to specialists, towards care that

has a more self-directed role for the patient. This self-direction raises concerns

regarding patient safety, chiefly around informed consent and continuity of care. In light

of these risks, it is important that we understand how family physicians assist Canadian

medical tourists. The analyses indicate that Canadian family physicians are currently

only cursorily involved, if at all, in supporting medical tourists in their medical practices.

This lack of engagement persists despite physicians’ willingness to be consulted and

involved. Improved support for medical tourists by their family doctors is hindered by

barriers amongst both stakeholder groups that might be addressed through guidance

from medical associations and patient advocacy organizations.

Keywords: medical tourism; family physicians, Canada; health geography; qualitative research; international medical travel

v

Acknowledgements

I am grateful for the efforts of all of the study participants who chose to share their

experiences and insights with me. Thanks go to Nadine Schuurman, Jeremy Snyder,

and all of the graduate students and research assistants in the health geography labs for

the questions posed and support they offered me throughout this research. Most of all, I

am boundlessly thankful for the unerring guidance and overwhelmingly deep and

substantial support Valorie Crooks has provided to me in the course of this degree. The

calibre of her supervision has been an inspiration and an honor to have been provided.

vi

Table of Contents

Approval .......................................................................................................................... ii Partial Copyright Licence ............................................................................................... iii Abstract .......................................................................................................................... iv Acknowledgements ......................................................................................................... v Table of Contents ........................................................................................................... vi List of Tables ................................................................................................................. viii List of Figures................................................................................................................. ix

1. CHAPTER ONE Introduction ................................................................................ 1 1.1. What is Health Geography? .................................................................................... 2 1.2. An Overview of Medical Tourism ............................................................................ 4 1.3. The Roles of Family Physicians in the Canadian Health System ............................ 9 1.4. Study Overview .................................................................................................... 11

1.4.1. Thesis Outline ........................................................................................... 13

2. CHAPTER TWO “I didn’t even know what I was looking for…”: A qualitative study of the decision-making processes of Canadian medical tourists .................................................................................................. 15

2.1. Abstract ................................................................................................................ 15 2.1.1. Background ............................................................................................... 15 2.1.2. Methods .................................................................................................... 15 2.1.3. Results ...................................................................................................... 16 2.1.4. Conclusions .............................................................................................. 16

2.2. Background .......................................................................................................... 16 2.3. Methods ............................................................................................................... 21

2.3.1. Recruitment .............................................................................................. 21 2.3.2. Data Collection .......................................................................................... 22 2.3.3. Analysis .................................................................................................... 23

2.4. Results ................................................................................................................. 24 2.4.1. Information Sources Consulted ................................................................. 26 2.4.2. Motivations, Considerations, and Timing ................................................... 28 2.4.3. Decision-Making Supports ........................................................................ 31

2.5. Discussion ............................................................................................................ 33 2.5.1. Wider Relevance ....................................................................................... 36 2.5.2. Limitations ................................................................................................. 38

2.6. Conclusions .......................................................................................................... 38

3. CHAPTER THREE “Our true role...is within the confines of our system”: Canadian family doctors’ roles and responsibilities towards outbound medical tourists ................................................................................. 40

3.1. Abstract ................................................................................................................ 40 3.1.1. Purpose .................................................................................................... 40 3.1.2. Methods .................................................................................................... 40 3.1.3. Results ...................................................................................................... 40 3.1.4. Conclusions .............................................................................................. 41

vii

3.2. Introduction .......................................................................................................... 41 3.3. Methods ............................................................................................................... 42 3.4. Results ................................................................................................................. 44

3.4.1. Pre-Trip Roles and Responsibilities .......................................................... 46 3.4.2. Post-Trip Roles and Responsibilities ......................................................... 47

3.5. Discussion ............................................................................................................ 48

4. CHAPTER FOUR Conclusion ............................................................................. 51 4.1. Overview .............................................................................................................. 51

4.1.1. Summary of Analyses ............................................................................... 51 4.2. Revisiting Objectives ............................................................................................ 54

4.2.1. Reported Engagement between Canadian Family Doctors and Outbound Medical Tourists ....................................................................... 54

4.2.2. Desired Engagement between Canadian Family Doctors and Outbound Medical Tourists ....................................................................... 56

4.2.3. Supporting Canadian Family Doctors and Outbound Medical Tourists ..................................................................................................... 58

4.3. Remaining Knowledge Gaps and Future Research Directions ............................. 59 4.4. Overall Limitations ................................................................................................ 60 4.5. Conclusion ........................................................................................................... 61

References ................................................................................................................... 63

viii

List of Tables

Table 1. Selected Interview Quotes ........................................................................... 23

Table 2. Participant Overview .................................................................................... 26

Table 3. Primary motivations to pursue surgery abroad reported by participants ....... 29

Table 4. Illustrative Quotes ........................................................................................ 45

ix

List of Figures

Figure 1. Destination countries visited by participants ................................................. 25

1

1. CHAPTER ONE Introduction

The term ‘medical tourism’ best describes the intentional pursuit of privately

arranged and purchased medical procedures at hospitals and clinics outside of a

person’s home country (Connell, 2012; Lunt et al., 2010). This stringent definition

excludes other forms of international medical travel such as medical care that is formally

referred to or arranged by physicians or health systems across national borders (i.e.

cross border care), emergency care sought by tourists while traveling, and routine

medical care accessed by ex-patriots while living abroad (Ehrbeck et al., 2008). While

related to these other types of international medical travel, medical tourism carries with it

unique concerns surrounding patient safety and health system impacts that are unique

(Burkett, 2007; Lunt et al., 2011; Turner, 2007a). I expand on these concerns and other

facets of the medical tourism industry in this chapter.

Medical tourism is an implicitly spatial practice. Patients travel across

international borders and navigate different social and medical landscapes in the hopes

of improving their health (Kangas, 2007; Whittaker, 2008). Despite its spatiality, the

topic of medical tourism has only just begun to be documented and explored by

geographers (Gatrell, 2011). In this Master’s thesis I work to better understand an

existing knowledge gap within medical tourism, that of the role of family physicians in the

decision-making processes of Canadian outbound medical tourists, using a health

geography lens. This chapter sets the context for the thesis by reviewing the relevant

background literature and providing an overview of its structure. In the section that

follows, I provide a brief overview of the scholarly tradition of health geography that

informs this research. Following this, I offer an overview of medical tourism research to

date and the knowledge gaps that spurred my Master’s thesis project. Finally, I close the

chapter with an overview of the study design and objectives that underpin my Master’s

research.

2

1.1. What is Health Geography?

While the influence of physical surroundings on the health of individuals and

populations has long been recognized and documented, scholarly inquiry by

geographers into how the social and cultural elements of place shape health has only

recently been undertaken within the auspices of ‘health geography’. Geographic

research concerning health was long defined by epidemiological accounts of the spatial

distribution of diseases and their ecological determinants as well as performing spatial

analyses for health services planning (Mayer, 1984; Rosenberg, 1998). This research

was heavily quantitative and fixed at the scale of populations (Jones & Moon, 1987;

Mayer & Meade, 1994). Accordingly, this domain of research developed with the

appropriately positivist label of ‘medical’ geography. The focus of medical geography

research during this period was primarily concerned with tracking disease and

rationalizing health service distribution, not with understanding health more broadly nor

how individuals understand their own health and its promotion (Jones & Moon, 1991;

Kearns, 1994).

Health geography emerged from the ‘cultural turn’ that influenced social sciences

departments worldwide in the latter quarter of the 20th century (Gesler, 1992). The

cultural turn describes a concerted movement away from a positivistic approach to

knowledge acquisition and interpretation, one which long-dominated the social sciences

in the post-WWII period (i.e. the ‘quantitative revolution’), to include more subjective and

nuanced qualitative research methods and critical frameworks (Barnes, 2001; Barnett,

1998). These methods and frameworks aim to understand the many interpretations and

meanings surrounding any given phenomenon instead of quantifying existing

understandings and outlooks that dominate conventional thought (Seale & Silverman,

1997). Scholars influenced by the cultural turn worked to distance themselves from the

mechanical and deterministic models that defined the social sciences in the post-WWII

period and instead engaged in scholarship that accepted the necessity of the uncertainty

and subjectivity that accompanies explorations of how cultural meanings are

constructed, interpreted, enacted, and maintained, especially at the level of individuals

(Barnes, 2001; Barnett, 1998).

3

The influence of the cultural turn was eventually felt within medical geography,

challenging the narrow definition of health that geographers had employed in focusing

on mapping disease and medical services (Jones & Moon, 1993). Kearns’ landmark

1993 paper “Towards a Reformed Medical Geography” firmly widened the boundaries of

the sub-discipline to become a more comprehensive ‘health geography.’ Kearns (1993)

sought to acknowledge the valuable traditions of medical geography but advanced the

argument that geographic inquiry into health had already moved beyond its origins of

spatial epidemiology and medical service planning towards explorations of the cultural,

social, and behavioural dimensions of health, and should continue to do so.

Consequently, ‘health geography’ includes the traditional quantitative spatial

epidemiological and health service planning research of medical geography as well as

qualitative research into how health is impacted and shaped by cultural and social

landscapes (Kearns, 2002; Rosenberg, 1998).

Health geography is a growing and vibrant sub-discipline of geography. Initially

centered in Canada, the United Kingdom, New Zealand, and the United States, health

geographers’ interests are broad and cross-cutting and the countries in which health

geographers are based are expanding rapidly. Spatial epidemiology and ecological

determinants of health remain as large domains of interest, but these have been joined

by studies of how health is defined, promoted, maintained, and/or otherwise impacted

amongst individuals and populations within their socio-cultural and physical contexts

(Kearns, 2002; Macintyre et al., 2002; Parr, 2002). This has led to a cross-pollination of

ideas from across the social sciences within the nexus of health geography. Domains of

interest that have emerged and developed since the formal demarcation of health

geography range widely, but those with some of the most intensive scholarly activity

include studies of food availability and security (e.g. Burns, 2007; Morland, 2009),

evaluations of health services access and uptake (e.g. Arcury et al., 2005; Poland et al.,

2005), analyses of neighbourhood walkability and health impacts (e.g. Berke et al.,

2007; Santana et al., 2009), and theorization of health promoting spaces and places (i.e.

therapeutic landscapes) (e.g. Milligan et al., 2004; Williams, 1998).

The development of health geography since its beginnings as medical geography

has incorporated qualitative methodologies such as case study, ethnographic and

phenomenological approaches while applying a broad number of analytic lenses,

4

including those oriented around gender (e.g. Dyck, 2003), disability (e.g. Crooks &

Chouinard, 2006; Dorn & Laws, 1994), racialized identity (e.g. Wang, 2007; Wilson,

2003;), rural studies (e.g. Cloutier-Fisher & Skinner, 2006; Parr et al., 2004), and urban

form (e.g. Curtis & Coutts, 2002; Douglas, 2008). Taken together, health geographers

have often worked to contest normative understandings of health, especially those that

ignore the constant interplay between people and their surroundings and fix health in

individual bodies, in an effort to diversify understandings of how health is socially and

culturally constructed. Health geographers have also sought to deepen our

understanding of how ecological and social determinants of health are patterned across

physical and social space while rooting these inquiries within the rich contexts they exist

by employing different methods and methodologies (Hayes, 1999).

Broadly speaking, health services research within health geography has primarily

focused on understanding how and why health services are (or are not) utilized by

populations and individuals. My Master’s research falls within this domain as it seeks to

better understand how and why Canadians choose to go abroad to access health

services and if their family physicians are incorporated into their care-seeking and in

what ways. Perhaps most significantly, this research marks a distinct move away from

analysing health services utilization at the local, regional, or national level that informs

much of existing health geography research and works to broaden the sub-discipline’s

focus to include health service provision at an international scale. As such, my research

responds to calls made to ‘scale up’ the focus of health services research in geography

and move beyond localized perspectives (Milligan & Power, 2009). The timing of my

research also coincides with a move towards thinking of ‘mobilities’ in health geography,

spearheaded by Gatrell (2011). As medical tourists are effectively patients mobilized at

a global scale, this research will help to inform debates that will surely emerge within the

discipline regarding the logistical and equity challenges that health mobilities pose to

existing health services planning.

1.2. An Overview of Medical Tourism

People have traveled to access health services for as long as renowned healers

and therapeutic spaces have existed. Early analogues for medical tourism include

5

pilgrimages to geothermal baths believed to have recuperative properties, retreats to

rural sanatoria to relieve breathing problems like tuberculosis and asthma, and medical

travel to visit well known physicians in distant cities (Connell, 2012; Howze, 2007).

Contemporary medical tourism has been foreshadowed by the long-established travels

of wealthy patients from across the globe to centres of medical excellence such as the

Mayo Clinic in Rochester, New York, as well as by strong networks of less wealthy but

similarly mobile international patients between countries in the Global South (Kangas,

2002; Lautier, 2008; Weisz, 2011). This earlier era of medical tourism is defined by

South to North and South to South movements of global patient flows. In the past two

decades, new networks of global patient flows have emerged that have connected

patients from countries in the Global North with access to medical care in countries in

the Global South (Forgione & Smith, 2006; Lautier, 2008). These networks have grown

tremendously in variety and size, and have served to informally connect national health

systems via international patients (Smith et al., 2009; Whittaker, 2008). These changes

in the direction of patient flow also mark a change in the composition of the medical

tourist market. Whereas medical tourism was previously largely restricted to the global

elite traveling to Northern centres of excellence and middle-income earners in the Global

South traveling to neighbouring nations for care not available in their home countries, the

new flows of patients from the Global North to the Global South are understood to be

increasingly composed of the middle and upper middle classes who traditionally have

relied on their domestic health systems for medical care (Connell, 2012; Ehrbeck et al.,

2008; Turner, 2007a).

The conditions that have given rise to recent shifts in international patient flows

are thought to involve three factors, those of improved quality of private medical care in

many Southern nations, the rise of the Internet, and the increasing ease and affordability

of international air travel (Connell, 2008). Private medical care has been the focus of

considerable domestic and international investment in many nations now serving as

medical tourism hubs. An example of this is Thailand, one of the earliest nations to

experience inflows of medical tourists, where marketing medical care to international

patients arose as a matter of fiscal necessity. Thailand’s economy boomed over the

course of the 1990s, resulting in a massive expansion of the country’s private medical

sector and an improvement in the quality of their services (Pachanee & Wibulpolprasert,

6

2006; Wilson, 2011). Domestic demand for private medical services sharply contracted

during the Asian financial crisis of 1997, forcing Thailand’s private hospitals to expand

their market in order to survive (Wilson, 2011). Thai hospitals established international

recruitment centres for patients in the United States, Saudi Arabia, and elsewhere as

well as online resources developed to attract patients (Wilson, 2011). A result of this

effort is a lasting inflow of international patients that remains to this day (Pachanee &

Wibulpolprasert, 2006; Wilson, 2011). Private hospitals in other nations not previously

known for the quality of their medical care, including Singapore, Costa Rica, India, Cuba,

and Malaysia, have followed suit in working to attract international patients, often with

the support of their national governments (Ormond, 2011; Turner, 2007a).

As with many other global industries, the globalizing influence of the Internet and

dense trade networks have been key in allowing medical tourism to grow in popularity.

Care providers are now able to disseminate information about their services directly to

international customers and consequently build their confidence in the quality of care

available, while the air travel of the early 21st century has enabled the transport of

patients to distant locations with relative ease and low cost when compared with

previous periods (Connell, 2008; Wilson, 2011). While barriers to accessing health care

have always existed and are found in all health systems, it is believed that these new

developments allow patients to easily identify and travel to places elsewhere in the world

to access care, thereby bypassing domestic care barriers (Ehrbeck et al., 2008). The

three barriers that are regularly cited as the main motivations for traveling abroad for

medical care are those of 1) unaffordable care, 2) long waiting periods for care, and 3)

poor quality of care (Ehrbeck et al., 2008; Turner, 2007a). The first two factors are

discussed purely in relation to privately financed and publicly financed health systems,

such as those of the United States and Canada, while the latter is mostly used in relation

to discussions of why outbound medical tourists emerge from lower income nations

(Ehrbeck et al., 2008). While the intuitive rationale for the importance of all of these

facilitative and motivational factors discussed above seem conceptually sound, there

remains a lack of rigorous and in-depth engagement with medical tourists themselves to

identify what motivates them to seek care and how they discover and arrange for care

abroad (Crooks et al., 2010).

7

Medical tourism has raised a number of concerns about potential heightened

health risks associated with traveling for medical care. Firstly, there are concerns that

combining air travel, especially long-haul flights, with surgical interventions can raise the

risk of medical complications such as heart attacks, strokes, and pulmonary embolisms

(Johnston et al., 2010). Blood clots, the root of all these issues, are associated with both

surgery and air travel and are consequently compounded when the two activities are

combined (Howze, 2007). Secondly, there is limited reliable third party regulation of

hospitals offering services to medical tourists in many destinations (Burkett, 2007). As

such, medical tourists are effectively charged with discerning high from low quality

medical providers on their own, greatly raising the medical risks for those who choose

sub-standard providers (Burkett, 2007). The final most commonly cited concern for

heightened risks is that of limited legal liability for medical providers in many emerging

destinations such as India and Thailand (Burkett, 2007; Howze, 2007; Turner, 2007).

Weak malpractice laws in these and other destinations shield physicians from

malpractice claims in cases of medical negligence, and expose international patients to

far more financial and physical risk than they may be accustomed to should they develop

complications or other care inadequacies (Burkett, 2007). It is unknown how aware

patients are of these risks and whether or not they involve professionals such as family

physicians in their interpretation (Crooks et al., 2010).

The growth of the medical tourism industry has often been linked with the

emergence of medical tourism ‘facilitators’, also called medical tourism brokers, which

are private companies that offer to arrange prospective international patients’ medical

tours abroad for a fee (Turner, 2007). Facilitators are usually located in a patient’s home

country and may serve as a first point of contact for prospective medical tourists who are

not comfortable arranging for their own international medical care (Turner, 2007; Snyder

et al., 2011a). In the Canadian context, it has been reported that facilitation is largely a

‘cottage industry’ of individuals with personal connections to medical providers abroad,

resulting in a wide range of professional attitudes and standards of care amongst

Canadian facilitators (Johnston et al., 2011). Some facilitators seek to support their

clients throughout their journeys and after their return while others restrict their

involvement to that of a one-time middleperson (Johnston et al., 2011). The facilitation

industry, both in Canada and worldwide, has a large online marketing and recruitment

8

presence, reinforcing the suggestion that the growth of medical tourism has been tied to

that of the Internet (Lunt et al., 2010; Penney et al., 2011). The lack of

professionalization amongst this group and their close relationship to medical

interventions has raised a number of patient safety concerns, primarily around informed

consent and unrealistic representations of medical risk (Penney et al., 2011). It is

currently unknown what proportion of medical tourists rely on facilitators and to what

degree they rely upon them in making their decisions to go abroad and for arranging

supportive care, providing another rationale for speaking with medical tourists

themselves.

In the context of Canada, outbound medical tourists that choose to leave the

domestic health system to access care abroad impact other users of the Canadian and

destination health systems as a whole both positively and negatively. This is true for

patients leaving other publicly-funded health systems. The most commonly cited positive

impact for a patient’s home health system is that of their removing themselves from

procedures that they are on a wait list for, benefiting other wait-listed patients behind

them in the queue (Johnston et al., 2010). It has also been speculated that in cases

where patients are on exceedingly long wait lists that may ultimately harm their long-

term health, such as permanent joint damage or the onset of diabetes from delayed

orthopaedic and bariatric surgeries respectively, choosing to go abroad will ultimately

lessen their cumulative lifetime burden on their provincial health and welfare systems

(Johnston et al., 2010). Critics of medical tourism provide counterpoints to these

purported benefits primarily by focusing on the excess burden placed on the Canadian

health system by medical tourists returning with costly complications, difficulties that may

not emerge for years following treatments such as surgery (Cheung & Wilson, 2007;

Turner, 2007a). It is further argued that outbound medical tourists from wealthy nations

who could otherwise access their surgery in their home country unjustly use the limited

health resources of the nations they travel to, driving up the cost of care for locals and

incentivizing the movement of health professionals into private health systems (Sen

Gupta, 2008; Turner, 2007a). There is currently little reliable evidence of these claims,

and the lack of consultation with medical tourists makes it unclear the degree to which

they are aware of these concerns when planning to go abroad (Crooks et al., 2010;

Johnston et al., 2010).

9

1.3. The Roles of Family Physicians in the Canadian Health System

The Canadian health system is not a unified whole. The financing and

administration of health services are handled at the provincial and territorial level,

resulting in thirteen separate health systems within the country (Romanow, 2002). The

structure and delivery of these separate health systems are closely aligned due to

significant federal involvement in their funding (Health Canada, 2010). Federal

legislation, of which the Canada Health Act is the most important, has attached

conditions to the social funding provided to the provinces by the federal government that

ensures universal access to care amongst Canadians (Romanow, 2002). These

conditions stipulate that all medically necessary care is: 1) publicly administered and not

for-profit, 2) available to all Canadian citizens, 3) ‘reasonably accessible’ to users, 4)

provided to Canadian citizens when in other provinces, and 5) comprehensively insured

(i.e. no medically necessary procedures can be excluded from public coverage)

(Romanow, 2002). As such, all Canadians are entitled to publicly insured health

services that are free of charge at the point of service. Importantly, medical necessity is

not defined in the Canada Health Act, resulting in variable coverage across the country

due to differing interpretation by the provinces and territories (Charles et al., 1997).

The absence of a cost barrier to publicly insured care in Canada ensures that no

Canadians are excluded from receiving medical care but it does require provincial health

systems to ration care for their users in order for them to function (Romanow, 2002).

Capacity limitations for any publicly insured medical services are experienced by health

system users in the form of delayed access to care (Romanow, 2002). Waits may

manifest at the primary care level in booking far ahead for a visit to the family physician

should there be not enough primary care providers in a region, or at the secondary or

tertiary level by being placed on a queue for medical diagnostic tests or intensive

treatments. These queues are dynamic and the positions of patients shift based on

physician assessments of the urgency of treatment (Naylor et al., 2000). When demand

for a treatment far outstrips system capacity, wait-lists can become excessively long and

negatively impact the well-being and satisfaction of health system users (Emery et al.,

2009; Romanow, 2002). Wait-lists have been used as evidence by advocates for health

system reform on both sides of the political spectrum as a rhetorically charged political

10

tool in pushing for increased public funding versus privatization of health services in

Canada (Church & Smith, 2009). In this context, medical tourism has been touted by its

advocates as a solution for individuals frustrated by wait lists (e.g. Horowitz &

Rosensweig, 2007; Law, 2008; Purdy & Fam, 2011). Wait-lists have dominated

speculation as to why Canadians would choose to privately pay for medical care they

are already insured for, and it has often been assumed to be a fact that wait-lists serve

as the primary motivation (Eggerston, 2006; Purdy & Fam, 2011). The lack of

consultation with Canadian medical tourists by researchers raises uncertainty as to the

degree wait-lists inform their decision-making, especially as some treatments Canadians

are known to go abroad for are not covered by public insurance, including elective

cosmetic and dental surgery (Crooks et al., 2010).

Family physicians play a key role in facilitating access to medical care in Canada.

While any Canadian can organize a visit to a primary care clinic, appointments with

medical specialists who are paid through provincial health insurance must be

coordinated with the help of a family physician, wherein family physicians are

gatekeepers to secondary and tertiary care in Canada (Health Council of Canada, 2010;

Romanow, 2002). If treatment is deemed by specialists to be medically necessary and

the patient a suitable candidate, family physicians play an important supportive role in

maintaining continuity of care (Health Council of Canada, 2010). Continuity of care is an

important tool in evaluating the quality of health services and describes the support

available to patients throughout their engagement with the health system (Haggerty et

al., 2003). Three forms of continuity of care are commonly considered in health system

and treatment evaluations; informational, relational, and treatment (Saultz, 2003).

Informational continuity of care refers to the quality of medical records in a patient’s

medical history and the ease at which records can be accessed and interpreted by care

providers (Saultz, 2003). Interpersonal or relational continuity of care is the quality of a

relationship between a care provider and their patient and the degree of trust and

knowledge shared between them (Saultz & Albedaiwi, 2004). Longitudinal or

management continuity of care describes the quality of support provided to patients

before, during, and following a medical procedure, and is important in ensuring a patient

is well informed of the risks of treatment and receives adequate follow-up care to

minimize the risk of complications (Haggerty et al., 2003; Saultz, 2003). It has been

11

suggested that medical tourism poses a clear threat to maintaining all forms of continuity

of care given the ability for patients to anonymously exit their home health system,

access care providers disconnected from their home health system, and return with little

or no documentation of their treatment (Leahy, 2008; Turner, 2007b). Family physicians

are uniquely positioned to support patients in maintaining all three forms of continuity

should they choose to go abroad by remaining a fixed and continuous point of contact

between a patient and the Canadian health system, (Turner, 2007b).

A close review of the medical tourism literature reveals that despite their

important role in decision-making, maintaining medical records, and coordinating

supportive care, family physicians have rarely been discussed. Meanwhile, family

physicians’ assistance to patients throughout their trajectory of care when seeking and

receiving medical treatments likely helps minimize the risks they encounter (Saultz &

Albedaiwi, 2004; Turner, 2007b). Given the lack of consultation with both medical

tourists and family physicians, it is unclear to what degree the role of family physicians in

patient education, providing referrals to reliable specialists, and coordinating follow-up

care carries over to patients seeking care outside of the Canadian system, if at all.

1.4. Study Overview

The research that comprises my thesis comes from two distinct analyses of data

gathered in two separate studies. In this section I briefly describe the structure of these

two studies and identify the objectives that informed the analyses that form the core of

this thesis.

My first analysis (Chapter 2) emerged as a subcomponent of a larger study led

by my supervisor (Dr. Valorie Crooks) and funded by the Canadian Institutes of Health

Research (CIHR). This larger study sought to better understand the ethical dimensions

of Canadian medical tourists’ decision-making by speaking with medical tourists to probe

how their decisions to travel abroad for care unfolded. As part of my thesis research I

conducted interviews with 32 former Canadian medical tourists who had traveled for

surgical care and worked to develop a sub-component of data collection (i.e. questions

in the interview guide) related to medical tourists’ engagement with the Canadian health

12

system. This subcomponent examined the role of family physicians in aiding decision-

making. This overall study and the subcomponent were motivated by the evident lack of

consultation with medical tourists in the existing medical tourism literature and the

resulting absence of empirically-informed claims within ongoing debates. Given the

health and safety risks to patients that have been speculated about in the existing

literature, there is a clear rationale for grounding these concerns in empirical accounts of

how medical tourists actually seek care abroad. Interviews with medical tourists were

held and thematic analytic methods used to interpret the resulting data. Three

objectives informed the analysis, which were to identify: (1) why Canadian medical

tourists decide to travel abroad for care, (2) how these medical tourists gather and

interpret information about treatment abroad, and (3) the social supports relied upon in

making their decisions, highlighting the role of their family physicians in doing so. A goal

of the overall study and my own subcomponent was to generate evidence that could

inform future informational interventions aimed at medical tourists that help to best

address their needs and help mitigate the health and safety risks they face.

Questions regarding the role of family physicians emerged over the course of the

above study and spurred our research team (under my leadership) to run a second

study, also funded by CIHR. This second study sought to identify what Canadian family

physicians saw their own roles and responsibilities to be towards Canadians that travel

abroad for care. Focus groups were held with family physicians across the province of

British Columbia and thematic analytic methods were employed to interpret the data

generated from the meetings. These focus groups were informed by three objectives,

which were to: (1) provide the first assessment of the kinds of experiences Canadian

family physicians have had with medical tourists in their practices, (2) articulate the kinds

of roles and responsibilities they are (not) willing to take on in supporting medical

tourists’ decisions and care abroad, and (3) identify what kinds of support are currently

available to Canadian family physicians regarding medical tourism and which are

prospectively perceived as useful in performing these roles. This study was intended to

help policy-makers and physicians with understanding the processes involved in medical

tourism and inform their efforts to improve patient care.

Taken together, my thesis aims to fulfill three overall objectives, which are to: (1)

comprehensively document if and how Canadians currently incorporate their family

13

physicians into their medical tours, (2) articulate realistic roles and responsibilities

Canadian family physicians have for the outbound medical tourists they care for, as

envisioned by physicians and patients themselves, and (3) identify supports for either

group that could help improve their engagement with one another regarding medical

tourism, ultimately working to reduce the risks faced by medical tourists and the resulting

burdens posed to the Canadian health system by the growth of the medical tourism

industry.

1.4.1. Thesis Outline

This section concludes the first of the four chapters that compose this thesis.

The second and third chapters are both structured as peer-reviewed journal articles.

Both have been submitted to academic journals for review, with the Chapter 2 having

been recently accepted for publication by Globalization & Health. Chapter 2 documents

an analysis of interviews with Canadian medical tourists and traces the common factors

and processes in their decision-making. The analysis highlights how medical tourists

gather and assess information on treatment abroad, what factors motivate and inform

their decision to travel for medical care, and what personal and professional supports

they rely upon to interpret these factors and information sources. The degree of

involvement by family physicians in supporting the participants spoken with throughout

their trajectories of their care was a key domain of inquiry and analysis. It is hoped that

this research helps address the many knowledge gaps that exist surrounding the push

and pull factors informing medical tourists’ behaviour and by doing so, inform effective

policy and informational interventions that can help ease the health and safety risks they

face.

Chapter 3 provides an analysis of six focus groups conducted with family

physicians across the province of British Columbia. The analysis reveals what kind of

role Canadian family physicians see as suitable for themselves with regard to treating

outbound medical tourists who are their patients, with the aim of both helping to ground

some of the emerging scholarly debates surrounding this issue. By doing so, it is hoped

that realistic and useful roles for family physicians can be articulated so that they can

best support and mitigate the health risks of this unique patient population.

14

The final chapter in this thesis brings together the themes and issues present in

Chapters 2 and 3 and examines what questions are answered and which are raised

when the two are examined together. Specifically, the final chapter identifies 1) how and

why family physicians are currently (not) incorporated into the journeys of medical

tourists from the perspectives of both of these groups and 2) what they see as a useful

and desirable engagement with one another to look like. By doing so, current barriers to

integrating family physicians into supporting medical tourists are comprehensively

identified and the points of agreement and divergence surrounding an idealized role for

family physicians between the two groups are noted. This chapter aims to reconcile

these envisioned roles and point to the future research questions for health geographers

and others engaging in medical tourism research.

15

2. CHAPTER TWO “I didn’t even know what I was looking for…”: A qualitative study of the decision-making processes of Canadian medical tourists

2.1. Abstract

2.1.1. Background

Medical tourism describes the private purchase and arrangement of medical care by

patients across international borders. Increasing numbers of medical facilities in

countries around the world are marketing their services to a receptive audience of

international patients, a phenomenon that has largely been made possible by the growth

of the Internet. The growth of the medical tourism industry has raised numerous

concerns around patient safety and global health equity. In spite of these concerns,

there is a lack of empirical research amongst medical tourism stakeholders. One such

gap is a lack of engagement with medical tourists themselves, where there is currently

little known about how medical tourists decide to access care abroad. We address this

gap through examining aspects of Canadian medical tourists’ decision-making

processes.

2.1.2. Methods

Semi-structured phone interviews were administered to 32 Canadians who had gone

abroad as medical tourists. Interviews touched on motivations, assessment of risks,

information seeking processes, and experiences at home and abroad. A thematic

analysis of the interview transcripts followed.

16

2.1.3. Results

Three overarching themes emerged from the interviews: (1) information sources

consulted; (2) motivations, considerations, and timing; and (3) personal and professional

supports drawn upon. Patient testimonials and word of mouth connections amongst

former medical tourists were accessed and relied upon more readily than the advice of

family physicians. Neutral, third-party information sources were limited, which resulted in

participants also relying on medical tourism facilitators and industry websites.

2.1.4. Conclusions

While Canadian medical tourists are often thought to be motivated by wait times for

surgery, cost and availability of procedures were common primary and secondary

motivations for participants, demonstrating that motivations are layered and dynamic.

The findings of this analysis offer a number of important factors that should be

considered in the development of informational interventions targeting medical tourists. It

is likely that trends observed amongst Canadian medical tourists apply to those from

other nations due to the key role the transnational medium of the Internet plays in

facilitating patients’ private international medical travel.

2.2. Background

The term ‘medical tourism’ describes the intentional movement of patients across

international borders to seek medical care that has been privately purchased and

arranged for (Bookman & Bookman, 2007; Snyder et al., 2011b). The elements of

intentionality and private arrangement are key to defining which care-seeking behaviours

constitute medical tourism as opposed to other forms of international medical travel such

as formal cross-border care arrangements and emergency care for vacationing tourists,

although the term has been used at times to describe all of these forms of care. The

global medical tourism industry is steadily growing, although accurate estimates of its

current size or scale are not available given the presence of exaggerated figures and

inconsistencies in tracking flow numbers, in part due to a poor universal definition of

what constitutes medical tourism (Johnston et al., 2010, Lunt et al., 2010). Despite this, it

is known that steady flows of patients traveling from the Global North (e.g., Canada, the

17

United States (US), Western Europe, Australia) to clinics in the Global South (e.g., India,

Thailand, Costa Rica) have emerged over the past decade (Lautier, 2008; Whittaker,

2008). These new patterns of trade have joined the long-established South–north and

North-North flows of international patients to internationally reputed medical centres,

such as the Mayo Clinic in the US, as well as existing flows of patients between

Southern nations (Cortez, 2008; Neelakantan, 2003). The growth of the medical tourism

industry has been made possible by increasingly globalized flows of trade,

transportation, and information (Lautier, 2008; Turner, 2007a). In turn, medical tourism

ties the interests of disparate populations together, for example by introducing novel

global pathways for the spread of infectious disease and through the sharing of scarce

health resources amongst citizens of different nations (Galbani et al., 2011; Sen Gupta,

2008).

A series of recent scholarly reviews about medical tourism have consistently

revealed that there are significant gaps in our understanding of this phenomenon

(Crooks et al., 2010; Hopkins et al., 2010; Lunt et al., 2011; Snyder et al., 2011b). In

addition, these reviews have indicated that much of the existing knowledge base is

derived from speculative claims (Johnston et al., 2010). These knowledge gaps persist

despite an increasing desire amongst global health researchers to better understand

medical tourism because of the implications this practice is thought to hold for the

equitable delivery of health services, the involvement of new actors (e.g. medical tourism

facilitators) in the delivery of health care, and the novel responsibilities of patients

seeking and physicians providing health care across international borders, among other

concerns (Pocock & Phua, 2011; Snyder et al., 2011b; Turner, 2011). For example, a

scoping review completed by Crooks et al. (Crooks et al., 2010) concluded that we have

much to learn about patients’ experiences of medical tourism, including how medical

tourists access and evaluate information sources prior to departure. Lunt et al.’s (in

press) more recent article echoes this conclusion, and identifies patient decision-making

as one of the priority areas for medical tourism research given its relevance to continuity

of care, patient health and safety, and the commodification of care. While media

accounts provide some valuable insights into the experiential dimensions of medical

tourism (CBC News, 2004; Loose, 2007; Olian, 2005), deep inquiry into the process of

patients’ medical travel, from conception to return, remains lacking. This absence of

18

knowledge leaves major questions about which factors and actors inform the decision-

making of medical tourists, especially in regard to their reliability and modes of

dissemination. In this article we address this knowledge gap through examining

Canadian medical tourists’ decision-making processes regarding seeking surgery

abroad.

Canadians are amongst those participating in the medical tourism industry, not

only as patients, but also as investors and facilitators (i.e., agents specialized in

coordinating international medical care, including arranging for visas and

accommodation and dealing with destination hospitals) (Snyder et al., 2011b). The only

quantitative report on medical tourism in Canada produced to-date indicates that 2% of

2,304 Canadian survey respondents have traveled outside the country to “consult with a

doctor, undergo a medical test or procedure, or receive treatment” (Purdy & Fam, 2011).

As a description of how this care has been paid for or arranged is not indicated, other

forms of international medical travel (e.g., cross border care arranged through the public

system) may be in the estimate. Further, 20 % of those surveyed indicated they would

travel abroad for private-pay health services (Purdy & Fam, 2011). Certainly, this is no

reliable indication of how many patients are indeed traveling abroad for private medical

care. Numbers aside, it is indeed the case that Canadian patients are choosing to take

part in medical tourism, a phenomenon that is receiving increasing media attention in the

country (Snyder et al., 2011b).

The phenomenon of Canadian patients privately choosing to travel outside of

their home health system to access medical care abroad is intriguing, as medically

necessary health care in Canada is publicly funded and universal. Federal legislation

limits the availability of domestic private health care, making privately purchased, on-

demand access for many treatments largely inaccessible to most Canadians (Health

Canada, 2010). There is no single Canadian health care system, as the management

and delivery of health care is the separate responsibility of each of the 13 provinces and

territories (Romanow, 2002). Canada’s federal government contributes to the financing

of each provincial health system through equalization payments that work to minimize

inequities in essential services, with the amount paid to each province differing on the

basis of need (Health Canada, 2010). The balkanization of the management and

financing of the national health system contributes to substantial differences in temporal

19

and spatial access to care across the country for the same procedures or treatments due

to differences in the priorities and resources of the health administrations in each

province or territory (Romanow, 2002). For example, in 2010 42% of patients in the

province of Nova Scotia had timely access to knee replacement surgery (i.e. within the

national benchmark period of six months between referral to specialist to surgery),

compared with 89% of patients in Ontario (Canadian Institutes for Health Information,

2011). These wait times are likely to serve as a prompt to consider care elsewhere for

some Canadian patients (Snyder et al., 2011b). Canadians also travel abroad for non-

medically-necessary procedures such as dental care and cosmetic surgeries that are not

covered by the public health care system. It has been speculated that procedure costs

are likely to serve as motivators for seeking such care abroad for Canadian patients

(Snyder et al., 2011b).

Much research exists about patients’ decision-making as it pertains to surgical

care sought domestically. It has been reported that patients are often hesitant to change

surgeons, even if it means an earlier surgical date, suggesting that trust and familiarity

with care providers and venues can outweigh other decision-making concerns such as

wait times (Conner-Spady et al., 2007; Schwartz et al., 2005). Striking a balance

between appropriate preparation times and meeting personal expectations of prompt

care is also a factor in patients’ decisions about if and when to receive care. For

example, it has been found that Canadian patients appreciate having time to prepare for

elective surgery and will seek to organize about two months between the booking date

and surgical date into their trajectory of care (Conner-Spady et al., 2009). However, if

this two month threshold is crossed, resentment builds as the wait time is generally

perceived to be excessive (Hodge et al., 2007). Another element of surgical decision-

making that has been explored is the sharing of information between physicians and

patients. While providing informed consent is a keystone principle of Western clinical

practice, it has been reported that the comprehensiveness of information shared

between surgeons and patients about the risks and benefits of surgery varies widely

(Etchells et al., 2011; Mishra et al., 2010). The outcomes of this information sharing are

thought to influence the willingness of patients to ultimately seek treatment (Etchells et

al., 2011). More generally, it has been shown that the ability of individuals to discern

statistical representations of the risks of surgical treatments are greatly influenced by

20

anecdotal accounts of procedure success or failure, suggesting that personal narratives

of treatment can be potent influences on patient decision-making (Freymuth & Ronan,

2004). In the current analysis we extend this existing body of knowledge by investigating

how the unique logistical and informational challenges posed by privately accessing care

internationally as a medical tourist coincide with or depart from receiving surgical care

domestically.

Existing understandings of patients’ decision-making for surgical care have yet to

consider the unique dimensions of medical tourism, such as concurrently seeking and

synthesizing information about surgical treatment, travel, foreign destinations, and how

the risks of each may interact to heighten the potential for negative health outcomes

(Alvarez et al., 2011; Lunt et al., 2011). While it is often speculated that medical tourists

rely primarily on the Internet to inform themselves about destination facilities, the

frequency of access to information found online and its actual influence on decision-

making requires dedicated attention (Lunt & Carrera, 2011; Sobo et al., 2011).

Furthermore, it is widely reported that medical tourists from particular source countries

seek care abroad based on singular motivations found in their home context, such as the

high cost of medical care in the US, limited availability of medical care in the Global

South, or long wait times for medical care in countries with public health care systems

such as Canada (Ehrbeck et al., 2008; Horowitz et al., 2008); yet, this tendency toward

simplistic accounts potentially belies complex interaction among the factors that compel

individuals to investigate seeking care abroad. We seek to unpack some of these

assumptions in the current analysis through examining the experiential accounts of 32

Canadians who sought private surgical care abroad.

The purpose of this article is to shed light onto how Canadian medical tourists go

about deciding to access surgery abroad and what kinds of information sources inform

their decisions. Our goal is to contribute to developing an empirically-informed

knowledge base about the global health services practice of medical tourism through

addressing the knowledge gaps identified above. Because of their exposure to a public

and universal health care system for medically necessary care at home, Canadian

medical tourists encounter an entirely different mode of access to care when privately

seeking surgery abroad, foregoing public payment for the ability to determine what kind

of care they wish to access, and when (Crooks et al., 2010; Eggerston, 2006). Even

21

when seeking surgical care that is not offered through the public system, such as

experimental surgeries only available in other countries or cosmetic procedures,

Canadian medical tourists are likely to encounter significant differences in facilitating

access to medical care abroad than they would domestically. These differences are

likely to include protocols around procedure booking and patient record transfer, among

other factors (Crooks et al., 2010). As such, Canadian medical tourists may need to

adopt more extensive roles as information assessors and decision-makers than they are

used to, shifting them from the more passive role of the traditional patient to the more

active, neo-liberalized position of the ‘patient-consumer’ (Ormond, 2011).

2.3. Methods

This analysis forms part of a larger exploratory study of the decision-making

processes and experiences of Canadian medical tourists. The study involved

interviewing Canadian medical tourists and medical tourism facilitators. This analysis

exclusively considers the former participant group.

2.3.1. Recruitment

We sought to recruit Canadians who had previously undergone surgical

treatment abroad for semi-structured phone interviews. As there is no organized tracking

or surveillance of this patient group, potential participants were identified through

numerous decentralized avenues. These included: (1) collecting names of medical

tourists from Canadian news reports and contacting them via phone or email; (2)

advertising in Canadian print news outlets; (3) posting invitations to participate on online

medical tourism forums; (4) snowball sampling through participants’ networks; and (5)

providing study details to facilitators to disseminate. No apparent differences emerged

between participants based on how they were recruited, such as in their motivations for

travel abroad or experiences of medical tourism. People interested in participating in an

interview were asked to contact a toll-free phone number or an e-mail address. Detailed

study information was provided upon contact and eligibility assessed. Upon establishing

a participant’s eligibility, an interview time was then scheduled.

22

Participation was limited to those who met the eligibility criteria of: (1) having

successfully pursued privately-arranged surgery outside of Canada paid for out-of-

pocket; (2) being enrolled in a Canadian public health care plan at the time of surgery;

and (3) being over the age of 18 at the time of the interview. To maintain focus,

participants who went abroad for care other than surgery (e.g., diagnostic testing, tooth

cleanings or fillings) were excluded. Those who had procedures that involved third

parties (e.g., transplants, some reproductive surgeries) were also excluded. This is

because confidentiality cannot be guaranteed to participants who report illegal activities,

as per Canadian research ethics policies, and it was thought that there is a risk among

this population that such activities would be discussed. Because we wanted to extend

confidentiality to participants, we did not include people who had had these surgeries in

the study. All those who scheduled an interview followed through with participating and

no participants elected to withdraw from the study after being interviewed. Prior to

participant recruitment, ethics approval was sought from and granted by the Office of

Research Ethics at Simon Fraser University.

2.3.2. Data Collection

Semi-structured interviews were conducted by phone between July and

November, 2010. A semi-structured approach was employed to allow common issues to

be explored, while giving participants the freedom to introduce unanticipated topics of

relevance to their experience. Table 1 includes selected questions from the interview

guide. All interviews were conducted by the same investigator (the lead author) in order

to enhance consistency. Interviews typically ran for 1–1.5 hours and were digitally

recorded. The interviews covered a wide range of topics, including participants’

motivations, assessment of risks, information seeking process, experiences in both the

domestic and international health systems, and pursuit of post-operative care. Data

collection ceased upon the exhaustion of all of our recruitment methods. This was

determined after no new participants were identified through public sources or contacted

us after a month-long period.

23

Table 1. Selected Interview Quotes

Selected Questions Sub-Probes

Tell me about when you traveled to ___________ for surgery.

What was it like?

What procedure did you get?

How long did you go for?

Did anyone accompany you?

Had you been to__________ before?

When was it that you traveled to __________________ for the procedure?

For how long before then had you been planning the trip?

For how long before then did you know or decide that you were going to get that surgery done?

Why did you decide to go to ______________?

Did anyone tell you about it?

What kinds of information did you look at?

Where did you get this information from?

Were personal finances an important deciding factor in choosing to go to _________?

Did you consult with your family doctor about your plan to go abroad for surgery?

2.3.3. Analysis

All interviews were transcribed verbatim. A review of the transcripts was

conducted by all authors. Following initial review, a meeting was held to share

impressions of common issues emerging from the interviews. A preliminary coding

scheme was constructed, which was structured around the agreed upon issues.

Generally speaking, scheme creation involved identifying umbrella terms or concepts to

which data segments were assigned that could be drawn together in different

combinations and permutations in order to inform a thematic analysis. Coding of the

transcripts followed, which was done using NVivo qualitative data management

software. To ensure the utility of the codes, one investigator undertook the coding while

another reviewed the first coded transcript to confirm the functionality and interpretation

of the scheme. Through an iterative process of coding and team discussion, superfluous

codes were eliminated and overpopulated single themes were disaggregated as part of

a second stage of coding. Upon completion of the coding process, thematic analysis was

undertaken. Thematic analysis involves reviewing coded data to finding patterns or

24

trends within the dataset that are compared to study objectives and existing knowledge

in order to refine the interpretation of their meaning (Aronson, 1994). By examining full

narrative accounts by theme, commonalities in particular domains emerged despite the

underlying structural differences (e.g., destination location, procedure type) in the

medical tourists’ raw accounts.

2.4. Results

In total, 32 medical tourists from eight of Canada’s 13 provinces and territories

were interviewed. On average, two years had elapsed from the time of the surgery

abroad to the time of the interview, with the longest being six years. Figure 1 and Table

2 provide an overview of some of the participants’ key characteristics. In total, 21

participants sought surgeries that were not available to them in Canada. Of these, six

sought procedures not approved in Canada, four were unable to receive referrals for

desired surgical care domestically, and 11 sought procedures where expertise was

lacking domestically.

25

Figure 1. Destination countries visited by participants

Note: This figure outlines where participants travelled for their procedures and how many went to each country. Note that one participant travelled to two countries for treatment addressing the same health problem, resulting in a total of 33 unique trips

26

Table 2. Participant Overview

Characteristic Count

Recruitment Method for Study Participation

Word of mouth (n = 9); Facilitator referral (n = 8); Study advertising (n = 7); Media reports (n = 5); Online testimonials (n = 3)

Province or Territory of Residence

British Columbia (n = 18); Newfoundland & Labrador (n = 3); Ontario (n = 3); Quebec (n = 2); Alberta (n = 2); Nova Scotia (n = 2); Manitoba (n = 1); Northwest Territories (n = 1)

Procedure Sought Abroad Orthopaedic surgery (n = 15); CCSVI therapy (n = 4); Eye surgery (n = 4); Bariatric surgery (n = 3); Cosmetic surgery (n = 3); Gastrointestinal surgery (n = 2); Dental surgery (n = 1)

Participant Ages Average of 53 years; Median of 50 years; Range from 22 to 80

Sex 19 females; 13 males

The processes by which participants discovered, researched, and ultimately

decided on pursuing medical care outside of Canada was extensively probed over the

course of the interviews. Three distinct themes emerged from the accounts of the

decision-making process: (1) information sources consulted during the decision-making

process, (2) motivations, considerations, and timing regarding accessing medical care

abroad, and (3) personal and professional supports drawn upon during the decision-

making process. These themes are expanded on in the remainder of this section. As

much as possible we have included verbatim quotations from the interviews in order to

enable the participants themselves to ‘speak’ to these issues. Quotations were selected

by the lead author as being a cogent representation of an issue assigned to a particular

theme, and independently confirmed as such by the other authors.

2.4.1. Information Sources Consulted

Participants identified four means of initially learning of medical tourism, namely:

word-of-mouth (n = 13), non-targeted Internet searches (n = 10), print and televised

27

media stories and advertising (n = 6), and familiarity with other countries’ health systems

due to their having emigrated from them (n = 2). One person could not remember how

she originally learned of medical tourism. For those who first learned of medical tourism

online, the possibility of accessing care abroad usually emerged as an extension of

researching treatments or trying to find an alternative means of accessing a surgery for

which they were wait-listed domestically. “I was looking for a magic bullet on the

Internet…to address the…wait list issue that I was facing and so I had no idea what was

out there…so I wasn’t actively seeking…I didn’t even know what I was looking for…I just

thought there had to be something else…” For those who learned about medical tourism

from other people, former medical tourists (ranging in intimacy from close friends to one-

off informal encounters), and friends and family with a passing knowledge of medical

tourism served as important prompters. One exceptional case emerged where a

Canadian family physician raised orthopaedic care abroad with multiple participants

amongst our dataset. While advertisements by medical tourism facilitators initiated some

participants’ decision-making processes, news stories were more influential in raising

participants’ awareness. Finally, for the two participants who were motivated by existing

familiarity with non-domestic health systems, medical care outside of Canada was

always seen as a possibility and there was no process of ‘discovering’ the option of care

abroad.

Upon first learning of medical tourism, the vast majority of participants relied

upon the Internet for detailed information. For these participants, it was used as a

research tool to access the websites of facilitators, destination hospitals, joint

replacement manufacturers, and empirical research. The Internet was also a powerful

social tool, facilitating contact between participants and former medical tourists who

provided personal anecdotes and advice. This communication sometimes took place in

the context of online forums, though it was also common for participants to contact

former medical tourists directly by e-mail. This sometimes resulted in having extended

telephone conversations about their experiences. Participants also used the Internet to

contact surgeons abroad directly for phone or e-mail consultations. These consultations

were often informed by the sharing of diagnostic scans or reports between the

prospective medical tourist and surgeon, the transmission of which was also facilitated

by the Internet. The most common fact-finding approach amongst the medical tourists

28

interviewed is characterized by this participant’s comments: “I had had so little care here

(in Canada) I figured it couldn’t be any worse over there. Maybe it could, I knew it was a

third world country, but after I researched the hospital on the Internet and I talked to the

four or five different people who went over there I had no concerns whatsoever.” Six

participants did not use the Internet at all in informing their decisions to go abroad,

relying instead on family members in the destination country to obtain and relay

information directly from and to the facility, the advice of former medical tourists, and/or

the information provided by facilitation companies.

Although it was not directly probed, few participants discussed how they

assessed the reliability of the information sources they consulted in the process of

learning about medical tourism. Some outlined basic quality and reliability assessment

practices. For example, one participant relied heavily on online physician rating sites,

saying “he (the surgeon) didn't have like any…bad write-ups online or anything… and

when I didn’t see anything bad I figured well it must be okay, because I’ve looked up

some doctors here for other things and I have seen bad comments.” Another participant

primarily relied upon a trusted hospital brand, saying “But there’s no real deep research,

it’s just uh a matter… (of) calling up your Mayo Clinic…on the computer screen, reading

a bit and making a few calls and going from there.” Other participants characterized

themselves as savvy researchers, suggesting their skills extend to assessing the

reliability of information, saying “…now when some people…say oh they do online

research…well sometimes they just mean that they’ve looked at a lot of ads, at

advertisements for this kind of thing (procedure)…I didn’t do that, I looked for statistical

surveys about the pros and cons of which procedure.” While the majority of participants

looked to the Internet as their primary information source, they commonly neglected to

clearly delineate or discern what kind of information was ultimately accessed or who

hosted it until they were prompted, while a minority made concerted attempts to convey

the effort invested in seeking out what they thought was accurate and neutral information

provided by third parties without commercial interests.

2.4.2. Motivations, Considerations, and Timing

Participants identified many different motivations that spurred their initial

consideration of medical tourism, which are summarized in Table 3. Despite this variety,

29

all of the motivations discussed fall into the three broad categories of seeking

procedures that are unavailable, wait-listed, or more costly in Canada. Cost was the

primary motivation to pursue care abroad for four participants, all of whom sought

cosmetic or dental surgeries that were available domestically for private purchase but

not covered under public Medicare. Of the 14 participants that identified wait-listing as a

key element motivating their trip, only seven ultimately pursued surgeries abroad that

were available (and for which they could be put on a wait-list) domestically. The other

seven concerned with wait-listing sought surgeries unavailable in their home provinces

or territories. These alternate procedures were often described as more technically

sophisticated and desirable than the domestic equivalent. These considerations became

a keystone in their decision to travel for care that combined with, and sometimes

eclipsed, the initial issue of wait-listing. Fourteen participants were solely motivated by

procedure availability, seeking procedures that were not available to them in their

provincial health or territorial system at the time of their medical travel. Reasons for this

unavailability included the procedure not being approved by safety regulators, the patient

being ineligible for surgery due to age or the absence of a diagnosis, or the lack of

domestic surgical expertise to perform the surgery.

Table 3. Primary motivations to pursue surgery abroad reported by participants

Primary Motivation(s) # of Participants

Availability (where the procedure is not available domestically) 14

Wait-listing (where the procedure is available domestically) 7

Combined wait-listing & availability (where being wait-listed prompted a search for alternative surgeries not available domestically)

7

Cost (where the procedure is not covered by public Medicare) 4

Participants were faced with choosing which destination facility to visit. For many,

the key deciding factor was the reputation of a surgeon they had found online and/or

through social networks. The quality of the surgeon was assessed by looking at where

s/he had trained, experience with the surgery, and/or testimonials from former patients.

The perceived skill of the surgeon regularly outweighed more practical concerns, such

30

as the possibility of encountering language barriers: “I went for the surgeon. That

was…the fundamental reason for going there. It was, not in terms of you know, where it

was, no. I went for the surgeon.” A group who deviated from this tendency to prioritize a

particular surgeon over other variables were those who went abroad for CCSVI therapy.

The majority who sought this procedure went to whichever clinic could treat them the

soonest, regardless of its location. Another group of participants who did not choose

their destination based on the surgeon were those returning to their countries of origin

for surgery. Related to this, some made decisions based on previous international travel

or living experience. The amount of in-hospital recuperation time offered also influenced

destination choice. Those who stressed the importance of this put a high premium on the

attention they would receive post-operatively, choosing the facility that would offer the

most lengthy and attentive recuperation period. Proximity of the destination to Canada

was relevant for some, but was never an overriding concern. Finally, cost was influential

to a varying degree. For some, the affordability of care in the Global South greatly

influenced their decision-making, as they would have accessed the surgery in a more

developed nation if they had the money. For example, “India was the cheapest of all of

the ones that I researched or the least expensive rather than cheapest. I didn’t mean to

cheapen it. The least expensive option was Chennai and that was a big factor…if I’d

been a millionaire…I would have gone to Britain.” Other participants reported finances

as being low on the decision-making hierarchy, characterizing it as unimportant when

compared with the other factors mentioned here.

There was great variety in the length of time it took participants to come to the

ultimate decision to travel abroad for medical care, ranging from ten years to one week.

Excluding the outlier of ten years, the average time from the discovery of the possibility

of going abroad for surgery to contacting a facilitator or destination hospital with the

intent to book a trip was six months (median = 3 months). This six month period was

commonly spent researching potential destinations, assessing risks, speaking with other

medical tourists, undertaking multiple calls or e-mails to facilitators and/or destination

clinics, and in some cases attending local information seminars arranged by facilities

seeking international patients. The time between booking and surgery was much more

compressed, ranging from under one week to six months, with the average being two

months (median = 2 months). For those who were assigned this two month period, it was

31

seen as a reasonable and desirable amount of time to get things in order prior to travel

and surgery while also giving time to arrange travel visas, where necessary.

2.4.3. Decision-Making Supports

Two groups of people were commonly reported to have played supportive roles

during participants’ decision-making processes. First, participants greatly appreciated

and heavily considered anecdotal accounts from former medical tourists. These

accounts were overwhelmingly positive endorsements of particular surgeons, destination

hospitals, and/or the practice of medical tourism itself. In fact, the majority of participants

sought advice from other medical tourists, ranging from reading online testimonials to

speaking directly with such individuals. The following account is characteristic of the

potency of these supportive encounters: “I talked to some (former medical tourists), one

guy especially who has been there a year before me…and his experience actually made

me really go for it and have no, no more doubts…(because) he said ‘it’s totally up to

standard, to Western standards, and a lot of people are trained in the West,’ and he said

the service was so good he would send his daughter there on her own.” Several

participants also reported being contacted ‘out of the blue’ by former medical tourists

who had heard about their upcoming trip through acquaintances or the local news media

and offered strong support and additional advice, further validating their decision to go

abroad for care. Second, family members played key supporting roles in helping to

research and interpret information. For at least four participants this support extended to

assistance with financing their medical care abroad. Although an important source of

support, the opinions of friends and family had little impact on the outcomes of the

decision-making process, with many participants adamant that they would have pursued

their medical tour with or without the approval of their family or friends. This conviction

was largely hypothetical, though, as none reported being seriously challenged by

anyone during their decision-making.

Although most participants reported visiting with either their family physician or

treating specialist during the time in which they were considering booking surgery

abroad, they rarely sought physicians’ advice during the decision-making process.

Instead, they more commonly waited to hear their regular physicians’ opinions on their

decisions after having made a booking. Interestingly, the perception that one’s family

32

physician or treating specialist would be unsupportive was cited as justification for not

informing them of the plan to go abroad for surgery prior to booking. For example, one

participant who did not speak with their family doctor explained that her surgery was

“None of his business… and he would have been prejudiced and he was prejudiced in

any case.” One of the most common reasons participants consulted with their regular

physicians prior to going abroad was to acquire medical records or diagnostic tests in

order to relay this information to destination physicians. While these physicians

commonly complied with participants’ requests for records and/or tests, their reaction to

the decision to go abroad for surgery ranged from supportive and caring to dismissive

and dissuading. Remaining neutral and offering neither support nor discouragement was

most common. Two examples of demonstrating uncommonly supportive family

physicians include one who brought up the possibility of pursuing surgery abroad to

patients before they had considered it and another who provided their personal cell

phone number for the patient to provide their overseas surgeon in the case of an

emergency to try and ensure a high degree of informational continuity. In both examples

these physicians served as a significant source of support and guidance during decision-

making.

Participants reported drawing on two industry-based sources of support in the

course of their decision-making, those of medical tourism facilitators and clinics abroad.

Ten participants reported using a medical tourism facilitator to arrange for care abroad.

Many of them solely relied upon the facilitator for information about their procedure, the

facility, and the surgeon abroad. For example, when asked “Did you hear about the

hospital that you went to in Bangalore from anyone else or was it just solely through the

recommendation of the facilitation company?” a participant replied “Yeah. That was

through the company that sent us; we had no idea where we were going.” In the course

of their decision-making, participants regularly reported having direct contact with their

surgeon abroad via e-mail, phone, or less commonly, at in-person information seminars.

Participants took the opportunity to ask questions regarding the potential risks of

surgery, probable outcomes, and their suitability for the procedure. These interactions

were greatly valued, and strengthened the resolve of many to access care abroad.

When asked what the main deciding factor was in seeking surgery abroad, one

participant appealed to these interactions with the surgeon, saying: “You know it

33

probably was the doctor, I can’t think of anything else…I was in touch with him two or

three times, he called me by telephone and spoke to him about a lot of the concerns and

things and…I think…he was the main factor."

2.5. Discussion

The opportunity to seek care abroad through the medical tourism industry

creates new means of acting on motivations and needs that have likely always

underpinned surgical decision-making in domestic contexts but may have been

constrained by structural arrangements. The current Canadian model of accessing

surgical care privileges the position of the expert over the non-expert by requiring

patients to seek referrals to tertiary care providers from their primary care physicians

(Watt, 1987), with the exception of surgical care not provided through the public health

care system. The medical tourists we spoke with, however, tended to seek advice and

information from many sources other than their regular physicians or other members of

the medical community and were ultimately responsible for deciding when and where

care was to be delivered as long as they could find a willing surgeon abroad. As such,

involvement in medical tourism changed participants’ typical enactment of the ‘patient

role’ and the means by which they decided on medical treatment. The significance of

these changes is discussed below in regard to participants’ layered motivations, the

timelines of care commonly seen, and the sources of information accessed and relied

upon in their decision-making processes.

The current literature on medical tourism broadly categorizes patient motivations,

typically attributing a single motivator to medical tourists from any given health system

(e.g., Horowitz et al., 2008; Singh & Gautam, 2012). In these accounts, Canadian

medical tourists have generally been afforded only one motivation for accessing medical

care abroad, that of wait-lists (e.g., Law, 2008). While wait-lists and wait-listing played a

role in motivating many of the participants to look for care outside of Canada, it is

important to note that participants provided examples of all three of the regularly cited

motivations for medical tourism, those of procedure cost, availability, and wait-listing

(Crooks et al., 2010). Given the lack of universal coverage by public insurance plans for

dental and cosmetic surgeries in Canada, it was not surprising to have heard accounts

of Canadians choosing to access these treatments at more affordable rates abroad.

34

Cost also served as a secondary motivator for many, serving to promote more affordable

destinations once participants were seriously researching their options for a specific

procedure abroad. The role of procedure availability played a far more nebulous role as

a motivator when compared with cost. It played a primary motivating role for those

seeking experimental surgeries (e.g., CCSVI, eye surgery for retinosis pigmentoria), as

there are no similar treatments available in Canada. It also served as a primary

motivator for those who were unable to get specialist referrals domestically, or whose

conditions were deemed inoperable by their domestic physician. Similarly, previous

discussions of medical tourists have rarely accounted for individual backgrounds that

might influence the countries they visit for medical care. Meanwhile, our analysis

suggests that previous exposure to foreign countries, either through travel or emigration,

might bear influence on the destinations they ultimately select.

For many participants who were initially motivated to explore the option of care

abroad as a result of having been wait-listed or being worried about the prospect of one,

the availability of procedures performed abroad which were perceived to be technically

superior supplanted this initial motivation. This supplantation of availability with wait-

listing was seen repeatedly for those who sought hip resurfacing, an alternative to a total

hip replacement, and vertical sleeve gastrectomies, a form of gastric bypass surgery.

Meanwhile, the desire to avoid a wait list for the same surgery available domestically

played a role in only six participants’ accounts. These layered motivations suggest that

the decision to access surgery abroad cannot be crudely reduced to a single motivator,

and that contextual elements and secondary motivators should be considered alongside

the most powerful motivator in any given account. Perhaps unsurprisingly, a common

element to all of the accounts was a strong hope that the surgery sought abroad would

improve the participants’ quality of life, as a sentiment of the importance of achieving

good health at any cost emerged in many of the interviews. If the barrier to a good

quality of life through surgery was perceived to be availability, cost, or a lengthy

domestic wait list, participants were compelled to find the means abroad to overcome

them, regardless of the procedure’s objectively scored urgency and/or necessity.

Notably, the particular contexts of individual destination countries were relatively

unimportant in most of participants’ decision-making processes. More specifically, the

particular details of a destination country’s wealth, politics, history, language, and other

35

characteristics were of minor importance when compared to the reputation of the

surgeon and the facility. In this way, the ‘global’ aspect of medical tourism is both

effaced and affirmed as the differences between potential destination nations disappear

and are replaced by placeless images of homogenous clinical spaces in the

imaginations of medical tourists. This finding departs from some of the conceptual

decision-making models that have been published in the tourism studies literature that

have emphasized the importance of destination nation characteristics to potential

medical tourists’ decision-making processes (e.g. Heung et al., 2010; Smith & Forgione,

2008).

While word-of-mouth information sharing has been noted as an important factor

in other studies of surgical patient decision-making (e.g., Hawker et al., 2001), the

degree to which word-of-mouth recommendations and endorsements serve as a primary

consideration for medical tourists was found to be remarkably consistent. This factor was

found to be equally important in a recent study of Omani medical tourists (Al-Hinai et al.,

2011). Another consistency among our participants was a general lack of consultation

with their regular physicians during the decision-making process. Within the Canadian

system, family doctors and other primary care physicians serve as a keystone in

patients’ pursuit of the majority of elective surgical care by assessing need, providing

counseling, and arranging for appointments with specialists who relay detailed

information about the risks and benefits of surgery (Bederman et al., 2010). Despite

these established roles in supporting patients’ medical decision-making, far more valued

was the advice and support provided by other medical tourists. This mirrors Kangas’

(2007) findings amongst Yemeni medical tourists, whose considerations of and where to

go abroad for medical care were deeply informed by word-of-mouth networks

recommending particular destination clinics and physicians.

While the value placed on the expertise from former medical tourists by those

engaging in decision-making around pursuing care abroad should not be discounted

given their first-hand knowledge of what to expect from particular hospitals or surgeons,

the conspicuous absence of a neutral, yet informed, third party informing the decision-

making process must be noted. Positive testimonials have been found to skew the

interpretation of surgical risk, resulting in a disproportionate weighting of the potential

positive outcomes even when presented with the statistical likelihood of the potential

36

negative outcomes (Freymuth & Ronan, 2004). This raises concern about whether or not

medical tourist are always in a position to give informed consent to care abroad based

on the information they have considered, given that such consent requires a sound

understanding prior to surgery of their condition, success rates, treatment options, and

risk of complication (Kangas, 2007; Mishra et al., 2010). Given the current lack of

comprehensive and neutral guidance available to medical tourists, there have been a

number of calls for stronger informational support by third-parties that do not have a

vested financial interest in medical tourism (Lunt & Carrera, 2011; Penney et al., 2011;

Turner, 2010). Knowing that former medical tourists play such an influential role in

informing prospective medical tourists could be useful to those designing such

interventions, wherein former medical tourists could be targeted in informational

campaigns with the intent of having them pass such information along to those

contacting them for advice. Furthermore, awareness of our finding of the wide variance

in the timing of the pre-booking research period by medical tourists and the relative two

month consistency of the post-booking period could aid in developing strategies to

disseminate informational interventions that are sensitive to the timeline of prospective

medical tourists’ informational needs.

2.5.1. Wider Relevance

The growth of the medical tourism industry has clear implications for global

health equity (Johnston et al., 2010; Turner, 2010). By extension, the decision-making

considerations of individual medical tourists and the information they access is tied to

the development of this industry and its potential to operate equitably and ethically. One

commonly cited health equity concern pertains to the use of public resources by the

private medical tourism industry (Johnston et al., 2010). Although much consideration

has been given in the medical tourism literature to the potential for patients to require

expensive follow-up care in their home countries (Birch et al., 2010; Cheung & Wilson,

2007; Crooks et al., 2010), our findings show that most of the medical tourists we spoke

with sought out some degree of advice or logistical support from their family physicians

and treating specialists prior to going abroad (but not necessarily before booking the

procedure). As primary care consults and many lab costs in Canada are covered by

public funding, this is another potential pathway through which public funds support the

operation of this private, for-profit industry. More research attention needs to be given to

37

uncovering the ways in which patients’ home health care systems indirectly support the

medical tourism industry in order to inform health equity debates surrounding this global

health services practice.

In terms of health equity in medical tourism destination countries, it is thought

that medical tourists traveling to economically developing nations may exacerbate

existing health inequities by raising the cost of care and/or lessening the availability of

specialists to local citizens through increasing demand for their services (Pachanee &

Wibulpolprasert, 2006). Meanwhile, it has also been suggested that the revenues from

medical tourists could be used to cross-subsidize the care local patients in order to

mitigate potential negative health equity impacts (Sen Gupta, 2008). Should the

appropriate redistributive financing mechanisms and regulations be developed in

destination countries or at individual facilities, medical tourists’ willingness to incur added

fees to access more equitable care is likely contingent on their understanding of the

health challenges faced by economically developing destination nations. Our findings

suggest a general lack of awareness amongst the medical tourists we spoke with in

terms of their knowledge of contextual details of the particular destinations they chose to

travel to during decision-making about seeking care abroad. In fact, consideration of the

destination country in any way held little weight in the decision-making process. Medical

tourists may more carefully consider health equity in the destination and the impacts of

their decisions if prompted to do so in informational interventions or through other means

and mediums.

While this analysis has focused specifically on Canadian medical tourists, our

findings have relevance for medical tourists from other nations. Here we highlight three

such issues. First, while the contextual details of medical tourists’ home health systems

may differ, they seek care in a common global marketplace. Our findings have confirmed

that this marketplace is largely mediated through the Internet, where much of the

information that prospective medical tourists consider is accessed online. Second,

amongst our participants, context-specific domestic health system considerations

informed their decision making processes. For example, particular strengths (e.g.,

universal access) and weaknesses (e.g., care rationing) of the Canadian public health

care system underlay the kinds of surgeries that were sought out-of-country and the

motivations to go abroad. Patients exiting other countries with universal public

38

healthcare coverage, such as the United Kingdom and Norway, may too be motivated to

go abroad for the same reasons at the Canadian medical tourists we spoke with. Third,

upon entering the same global marketplace, potential medical tourists are exposed to

many of the same web pages and advertisements regardless of the regulatory, legal,

and political environments from which they will depart. This reality underscores the

importance of thinking of this patient group as influenced, but not strictly defined by, their

home health system contexts.

2.5.2. Limitations

As recruitment was limited to English, we have excluded French-language

participants as well as other linguistic minorities who do not have spoken English

fluency. Additionally, given the difficulty of recruiting the study population and our

subsequent reliance on snowball sampling, there is likely a disproportionate focus on

particular surgeries sought in specific destinations and medical tourists from certain

regions of Canada. Finally, our reliance on the retrospective recollections may have

resulted in the omission of key details and/or heightened the bias of their recall of events

when compared with a prospective approach to data collection.

2.6. Conclusions

In this article we have presented the findings of interviews with 32 Canadian

medical tourists, with a specific focus on their decision-making processes regarding

seeking surgery abroad. Our analysis confirms accounts of medical tourism that attribute

its growth to the ability of the Internet to connect distant parties with mutual interests to

one another (Connell, 2006; Moore, 2009). That prospective Canadian medical tourists

relied upon the Internet to put them in touch with information about clinics, surgeons,

and other medical tourists is therefore not surprising. What is noteworthy, however, is

the degree to which the opinions and advice of other medical tourists informed

participants’ awareness of medical tourism and their ultimate decision to travel abroad

for care. This adds evidence to existing concerns that prospective medical tourists may

have limited access to accurate and unbiased sources of information about their

treatments, especially online (Lunt & Carrera, 2011; Turner 2011a). The creation of such

39

sources could greatly benefit all medical tourists considering surgery abroad by

providing a more complete picture to inform their decision-making.

The accounts provided by Canadian medical tourists complicate existing broad

characterizations in the medical tourism literature that attribute the motivations of

medical tourists leaving any given country to a single motivating force, such as cost of

care, wait-listing, or the availability of procedures. The medical tourists we interviewed

made it clear that all three of these motivators were at play in their decision to seek care

abroad, often in combination with one another. Future accounts or investigations of

medical tourism would benefit from a more nuanced consideration of the layered

motivations that are driving patients to seek medical care abroad, rather than accepting

the current broad-stroke accounts that attribute a single motivator to the medical tourists

of any one locale. It is also important that future research addresses the quantitative

knowledge gaps rife in medical tourism research to provide broader context and

grounding for the trends described in this analysis and other qualitative studies.

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3. CHAPTER THREE “Our true role...is within the confines of our system”: Canadian family doctors’ roles and responsibilities towards outbound medical tourists

3.1. Abstract

3.1.1. Purpose

Medical tourism is a growing mode of health care delivery that poses novel challenges to

family doctors. This study explores how Canadian family doctors understand their roles

and responsibilities towards patients that seek health care abroad as outbound medical

tourists.

3.1.2. Methods

Six focus groups were held with 22 family doctors across the province of British

Columbia in 2011. Thematic analysis of the transcripts identified cross-cutting themes.

3.1.3. Results

Canadian family doctors find that medical tourism threatens patients’ continuity of care.

Informational continuity is disrupted prior to patients’ going abroad by regular omission of

family doctors from pre-operative planning and upon return home when patients lack

complete or translated medical reports. Participants felt that their responsibilities to

patients resumed once they had returned from care abroad, but were worried about not

being able to provide adequate follow-up care. Participants were also concerned about

bearing legal liability towards patients should they be requested to clinically support a

treatment started abroad.

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3.1.4. Conclusions

Medical tourism poses challenges to Canadian family doctors when trying to reconcile

their traditional roles and responsibilities with the novel demands of private out-of-

country care pursued by their patients. Informational tools to help patient decision-

making and guidance from professional bodies regarding physicians’ responsibilities to

Canadian medical tourists are seen as currently missing. Developing these supports

would help address challenges faced in clinical practice.

3.2. Introduction

Medical tourism is the intentional pursuit of privately-purchased and arranged-for

medical care outside a patient’s home country (Bookman & Bookman, 2007). This care

occurs outside established cross-border care arrangements and typically without

physician referral. Information about clinics and procedures abroad is readily available

to prospective patients online, which has propelled recent growth of the medical tourism

industry (Connell, 2011; Lunt et al., 2010). Concurrently, the confidence of international

patients in the quality of care available abroad has been bolstered by marketing

campaigns for medical tourism by various hospitals and national governments (Crooks

et al., 2011; Leng, 2010). Medical tourists may choose to arrange for their own care

abroad or use the services of ‘facilitators’ – agents who specialize in booking

international medical travel but who typically have no medical training (Cormany &

Baloglu, 2011; Turner, 2011).

While the phenomenon of people traveling abroad to access medical care is not

new, the increasing scale of international medical travel is (Whittaker, 2008).

Meanwhile, little empirical research has been done to examine how these international

networks of care impact outbound medical tourists’ domestic primary care systems,

including Canada’s (Hopkins et al., 2010; Johnston et al., 2010) – wherein Canadian

patients are known to be taking part in medical tourism (Crooks et al., 2011; Turner,

2011b). Canada’s healthcare system uses a single-payer model (i.e. publicly funded

and administrated) to ensure universal coverage for necessary services. As such,

access to public healthcare is rationed (Romanow, 2002). Canadian family doctors play

42

a key role in this rationing by serving as ‘gatekeepers’ to diagnostic and surgical

services, providing assessments of need, and offering referral beyond primary care

when warranted. Medical tourism challenges this gate-keeping role by allowing

Canadian patients to circumvent their family doctors and access specialized or surgical

care on demand. This alteration to the usual trajectory of care has raised concerns

regarding patient safety, interruptions to continuity of care, and the quality of informed

consent (Lunt & Carrera, 2010; Snyder et al., 2011a; Turner, 2007b). However, these

concerns have remained primarily speculative due in part to the lack of consultation with

primary care providers about medical tourism. In this article we begin to address the

knowledge gap identified above by reporting the findings from focus groups held with

Canadian family doctors about outbound medical tourism. We conducted thematic

analysis of this data to qualitatively explore what family doctors see their roles and

responsibilities to be for patients in their practices who seek medical care abroad as

medical tourists. Our findings raise questions about family doctors’ responsibilities

towards these patients and clarify some implications of medical tourism for Canadian

family medicine practice. These findings can inform action or intervention development

in other similar countries experiencing outflows of patients pursuing medical tourism,

such as Australia, Britain, and the United States (Cheung & Wilson, 2007; Ehrbeck et al.,

2008).

3.3. Methods

The purpose of this qualitative study is to identify the implications of patients’

engagement in medical tourism for surgical interventions for family medicine practice in

the Canadian province of British Columbia (BC). We focused on BC not only because it

is where we, a team of health services researchers and social scientists with domain

expertise in medical tourism and family medicine, are based but also because it is a

province known to be home to medical tourists and several facilitation agencies17. In

summer 2011, six focus groups were held in six BC cities that provided representation

from all provincial health authorities. Focus groups were organized to offer a forum for

BC family doctors to discuss their experiences and concerns about outbound medical

tourism. Focus groups are a useful method in exploratory research such as this where

participants may not have enough to say on their own to warrant being interviewed, and

43

where ideas exchanged amongst participants might spur ideas that would remain

uncovered through one-on-one conversation (Sim, 1998).

Prior to recruitment, ethics approval was granted by the Research Ethics Board

at the authors’ institution. Participant eligibility was limited to family doctors currently

practicing in one of the six cities. Potential participants were identified using the BC

College of Family Physicians website, where the contact information for all practicing

family doctors was gathered. Letters of invitation were faxed to all of the practices

identified, from which interested doctors followed up with the lead author for further

information and consent forms. This information indicated that CND$150 would be given

to participants to acknowledge their contributions to the study. A notable limitation of our

recruitment strategy is that it was limited to a single Canadian province and

subsequently may not capture the full range of issues that may be present across

Canada. Focus groups took place at meeting rooms in hotels or university campuses in

the six cities. Two moderators and a note-taker were present at each. The focus groups

were loosely structured around a series of pre-determined probes that explored the:

experiences participants had with medical tourists in their practices; concerns and/or

benefits medical tourism offered their patients; and usefulness of current and

prospective informational tools available to patients considering medical tourism. As is

standard with focus groups, moderation was only used to keep conversation going or to

move discussion on to new or more pertinent topics (Sim, 1998).

Focus groups ran from 1.5 to 2 hours and were digitally recorded and transcribed

verbatim. Following data collection, transcripts were uploaded into NVivo, a qualitative

data management program, for coding. A coding scheme was iteratively developed with

input from all authors following full transcript review and confirmation of consensus on

key emerging themes when compared to the study aims and existing literature on

medical tourism. Inductive and deductive organizational codes that structure these

themes were identified, which formed the coding scheme. Coding was performed by the

lead author. The cross-interpretability of the coding scheme and its application to the

dataset was verified by the second author following coding of the first transcript.

Following coding, the content of each code (i.e., the coding extracts) was

comprehensively reviewed across the six focus groups in order to ascertain the breadth

44

and depth of identified themes. The interpretability of these themes was confirmed by

the first three authors following the coding process, wherein patterns and outliers for

each theme were discussed. A key theme emerging from the transcripts and confirmed

through coding extract review pertained to family doctors’ roles and responsibilities

towards patients engaging in medical tourism, which is what is examined in this article.

Quotes that best suit the scope and breadth of this theme were identified for inclusion by

the first and second authors and confirmed by the others.

3.4. Results

In total, 22 family doctors participated in this study. They had been practicing

family medicine for an average of 23 years. Twenty had at least one patient in their

practices that had opted for medical tourism. The number of medical tourists they

estimated that they had encountered over their careers ranged from one to 90 (median =

6). In the remainder of this section we present the findings of the focus groups.

Findings are organized as themes central to the roles and responsibilities of doctors to

their patients who seek healthcare as medical tourists. These themes are distinguished

between pre-trip versus post-trip roles and responsibilities, and concerns versus desires

surrounding their potential or realized roles. Table 1 contains verbatim quotes that

characterize key themes.

45

Table 4. Illustrative Quotes

Quote #

Quote Text

1 “I don’t feel it’s my responsibility as a…family physician to research this (clinic abroad or surgical intervention being sought) or to council…where to go and anything of that sort, other than to (alert them to) be cautious and…they may be getting something they didn’t bargain for” (FG-K, pg.10)

2 “...if a patient comes to me and says ‘the purpose of my visit today is to talk about maybe I want to go to India’, there’s no diagnostic code for ‘I want to go to India, you know’ so I’m not actually supposed to bill for that right. So there is no benefit for us” (FG-N p.1, pg.6)

3 “(Patients) haphazardly discuss one or two things with you and then they’re gone before you know and they come back (after surgery abroad) and there hasn’t really been a plan or, or time to work out what we’ll do when you get back, or a lot of them go without letting us know” (FG-V, pg.26)

4 “...no matter where (my patients are) seeking medical care I still have that sense of: I’m their family doctor and I’m going to want to work with them if they have complications. But if they’re someone (who goes abroad and) I don’t know about it then...I’m out of that loop” (FG-PG, pg.15)

5 “...it’s frustrating for us (family doctors) when they (patients) come back with all the results, half of them in a different language or not in metric or whatever and then you have to sort all this out and you know we’re in a small business that has five to ten minutes per patient and we’re expected to solve all those issues as well as the day to day maintenance of the patient” (FG-V, pg.20)

6 “So would I accept the patient back and treat those complications, yeah absolutely, they’re my patient. I’m a family doctor, you know that's my responsibility and that's also what you do as family physicians…we try to do the best for our patients at all times, all situations” (FG-PG, pg.20)

7 “…you know I have patients going abroad, getting care and then they come back and the physician (from the destination facility) and the patient expect me to continue care, so providing certain types of medication, certain types of injections because the patient can’t stay down there for all of their treatment, so I’m doing something that I’m just not really comfortable with and its being dictated by someone else abroad and thinking well what happens if there’s a complication, who is now going to be on the hook for liability” (FG-B, pg.6)

8 “I don’t see much benefit for us in family practice because (outbound medical tourism) diverts our true role. Our true role... is to guide our patients in their journey towards health in our system right within the confines of our system” (FG-N, pg.14)

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3.4.1. Pre-Trip Roles and Responsibilities

Concerns emerged across all focus groups regarding pre-trip consultations with

patients considering medical tourism. Foremost amongst these was that prospective

medical tourists often expect family doctors to help interpret research about desired

procedures or clinics abroad. Many participants recounted being presented with an

overwhelming amount of marketing materials and website print-offs. Participants

expressed that it was impossible to satisfy these requests as there is not enough time

during one consult to review the material and address patients’ concerns. Participants

also thought it was unreasonable to expect them to be familiar with details of the

destination providers, the countries where care was offered, and/or the procedures

sought, especially those that are experimental (Table 1, quote 1). Compounding their

hesitance to speak beyond their level of familiarity was the absence of a billing code for

medical tourism consults, offering them no way to be compensated (Table 1, quote 2).

Most participants had experienced situations where their patients did not consult

with them prior to going abroad, only to learn about the procedure after it had been

performed (Table 1, quote 3). Participants expressed concern for the well-being of their

patients and felt it was important to have the opportunity to help broadly examine the

pros and cons of the medical interventions being considered and to discuss the potential

risks involved prior to a patient booking care in another country. Some of participants

saw a patient’s consideration of medical tourism as a possible indicator of navigational

challenges within the Canadian healthcare system. Participants across the focus groups

thus thought that many patients seeking care abroad would be best helped by first

advocating for their patient and ensuring their options within the domestic system were

exhausted.

Many participants experienced medical tourism as disruptive to the provision of

continuous care, and were concerned when they were totally omitted from the planning

stage (Table 1, quote 4). This concern about informational discontinuity did not extend

to a desire to be involved in facilitating the provision of out-of-country care prior to a

patient’s travel, for example by prescribing prophylactic medications for infection.

Examples from some participants’ own experiences were offered to demonstrate how a

lack of willingness to offer pre-trip support could damage relationships with patients and

47

threaten continuity of care. It was agreed that providing (usually limited) input or

guidance in the planning stage could enhance the ongoing doctor-patient relationship,

particularly when the procedure being sought abroad was thought of as life-changing or -

saving.

3.4.2. Post-Trip Roles and Responsibilities

The potential for disrupted continuity of care following a patient’s private pursuit

of medical care abroad was a major issue raised by all participants. For example,

instances where informational continuity had been disrupted by poor or non-existent

documentation of procedures or post-operative care orders were reported to be

common, as were patients returning with treatment documentation in languages other

than English or using diagnostic metrics not used in Canada. Both of these issues made

interpreting or integrating surgical interventions sought abroad into a patient’s history

difficult (Table 1, quote 5).

All participants expressed a strong conviction that they held a responsibility to

provide post-operative care for their patients as best as they were able to regardless of

where the original treatment was obtained (Table 1, quote 6). Uncertainty emerged

regarding what forms this post-operative care or support should appropriately take. For

example, concern was raised about taking on liability for post-operative care should it

involve treatments prescribed by an out-of-country physician, especially when the care

they were being asked to provide followed an experimental procedure not approved in

Canada (Table 1, quote 7). Another concern pertained to arranging post-operative

specialist care for medical tourists upon their return. Some participants had directly

experienced specialists refusing to provide post-operative care for these patients.

Others expressed concern about the potential for encountering problems in forwarding

medical tourists within their referral networks as a very real possibility. Participants felt

that these post-operative care concerns needed to be clearly communicated to

prospective medical tourists, and that they reinforced the importance of pre-trip

consultations between family doctors and their patients.

48

3.5. Discussion

The family doctors we spoke with indicated a preference for a limited role when

their patients seek private medical treatment outside of Canada. Liability concerns and

knowledge limitations made participants think that many of the responsibilities

associated with their routine gate-keeping role for domestic care, such as coordinating

with specialists and helping in surgical decision-making, are not transferable to outbound

medical tourists. Participants did wish to be involved in the decision-making process to

the point of exploring the motivations behind a patient’s consideration of medical tourism

and to ensure options within the domestic system are exhausted before patients went

abroad. They also wanted to help patients achieve an accurate understanding of the

potential risks, costs, and benefits of the medical care they were seeking abroad. At the

same time, they did not see any significant role for themselves as a researcher or

interpreter for information when discussing decision-making. Quote 8 (Table 1)

succinctly captures one of the primary reasons for this. This finding runs counter to calls

made by some scholars for family doctors to offer detailed counsel and specific

recommendations when patients consider medical care abroad (Crozier & Baylis, 2010;

Levine & Wolf, 2012), and demonstrates the importance of seeking input directly from

family doctors prior to putting forth recommendations about their roles and

responsibilities towards medical tourists.

Family doctors strongly felt their roles and responsibilities for facilitating and

administering post-operative care within Canada remained the same regardless of

where initial treatment was obtained. These responsibilities were less certain in cases

where the procedure was experimental or poorly documented. Our analysis revealed

that the desired roles of family doctors in providing or coordinating post-operative care

could be enabled by improving informational continuity of care standards in the practice

of medical tourism. For example, encouraging pre-trip contact between patients and

their family doctors to discuss appropriate documentation could assist these same

doctors in caring for their patients upon return home. The concern expressed by

numerous participants that there may be difficulties finding a specialist willing to provide

post-operative care for a patient who has sought surgery abroad confirms speculation

that this is an implication of outbound medical tourism for patients’ home healthcare

49

systems (Cortez, 2008). This concern also indicates a need for patients to be clearly

informed of what kind of post-operative care will be available to them in their home

system when pursuing medical tourism. Participants felt that there was a lack of

external guidance from professional and regulatory bodies to help them with

understanding if and how they should assist medical tourists while protecting themselves

from legal liability. They wanted guidance on what their roles and responsibilities

towards these patients were. They also expressed concern over the lack of guidance

available to Canadian patients considering medical tourism. While a minority of

participants thought that the creation of informational tools aimed at patients or family

doctors would be an ‘admission of failure’ by the Canadian healthcare system, most saw

such tools as desirable. Simple informational interventions were favoured, including

pamphlets or websites that outline common surgical risks, potential limitations of

Canadian system responses to complications from surgery, and questions for patients to

ask their surgeons abroad. Given the knowledge limitations of family doctors around

specific procedures and destinations and the limited time available to them to counsel

patients, it was generally agreed that such informational supports would be very useful

to direct patients to the tools to review in their own time. This desire for informational

interventions for medical tourists and health professionals is consistent with the findings

of other studies (Crozier & Baylis, 2010; Lunt et al., 2010; Turner, 2011a), including one

involving health administrators responsible for patient safety in BC (Crooks et al.,

2011b).

While this analysis is limited to the perspectives of Canadian family doctors in 6

BC communities, the findings are transferrable to a range of healthcare contexts. Here

we highlight two main points. First, family doctors play a key role in supporting

informational continuity for their patients across many health systems (Stokes et al.,

2005), and are thus likely to be concerned about the implications of medical tourism on

their own practice regardless of the system in which they are based. This analysis

suggests that in light of the existing role of family doctors in supporting continuity of care,

family doctors must be considered in creating effective responses that aim to improve

the health and safety of medical tourists. Second, family doctors beyond Canada will

also conceivably be faced with liability concerns similar to those raised in the current

study related to patients seeking detailed advice prior to their trips or the administration

50

of post-operative care prescribed by out-of-country physicians. As such, those

practicing in other health systems may also see the benefit in the development of

informational tools or other resources for family doctors that provide guidance on what

their specific roles and responsibilities are towards these patients.

The growth of medical tourism will likely continue to intensify as networks of trade

continue to deepen and more care providers seek to attract foreign patients (Carrera &

Bridges, 2006; Connell, 2011; Whittaker, 2008). Family doctors are well positioned to

help ameliorate some of the potential health risks and continuity of care challenges

posed by this form of care by educating patients, ensuring international treatments are

properly documented, and enabling access to domestic postoperative care (Crooks &

Snyder, 2011; Turner, 2007b). Our findings indicate that Canadian family doctors are

willing to take on these responsibilities when provided the appropriate supports to do so.

51

4. CHAPTER FOUR Conclusion

4.1. Overview

The two analyses that comprise this thesis have addressed important knowledge

gaps about medical tourism. The first analysis (Chapter 2) presented the findings of

interviews conducted with medical tourists while the second (Chapter 3) presented the

findings of focus groups conducted with Canadian family doctors. These analyses work

together to meet my overall thesis objectives, which are to: (1) document the degree of

involvement of Canadian family doctors in the care trajectories of outbound medical

tourists, (2) articulate a realistic set of roles and responsibilities between family doctors

and medical tourists using the perspectives and experiences reported by both

stakeholder groups, and (3) identify what informational supports are currently available

to both groups in order to identify existing gaps and suggest possible solutions to

addressing currently unmet needs. In the current chapter I revisit these objectives in

light the findings presented in of Chapters 2 and 3, with the intent of articulating their

shared significance. To accomplish this I first summarize the key findings in both

analyses and then move to bring together both sets of findings as they relate to my

objectives. I conclude by reflecting on directions for future research.

4.1.1. Summary of Analyses

The analyses included in my thesis worked to include the perspectives of both

Canadian medical tourists and family doctors in order to explore the phenomenon of

outbound medical tourism from Canada. Chapter 2 provided the results of a thematic

analysis of interviews with 32 Canadian medical tourists. This analysis achieved a

detailed understanding of why and how this group chose to travel abroad, and identified

who they relied upon during their decision-making processes. Informed by the rationale

that family doctors are key players in facilitating patients’ access to secondary and

52

tertiary care in Canada (Chan et al., 2003; Romanow, 2002), the analysis sought to

parse out what role, if any, family doctors played in participants’ international surgical

care trajectories. By demonstrating that motivations are varied and multi-layered, rather

than homogenous and singular, the findings of this analysis disrupted some dominant

assumptions about patient motivations that are widely found in the existing medical

tourism literature. The findings also confirmed the importance of the Internet in driving

the growth of medical tourism. Related to this, it was found that family doctors were

largely excluded from participants’ decision-making. When examined together, these

findings provided evidence that medical tourism represents a shift towards a patient-as-

consumer framework of medical care delivery that departs from the traditional structures

and ethos of the Canadian health system. While this departure poses numerous

challenges, two dominant issues arose. Firstly, informational resources that are readily

available to medical tourists are primarily provided by the medical tourism industry, not

by a neutral and informed third party, and are therefore likely to incorporate a misleading

bias. Secondly, Canadian medical tourists often do not engage with the domestic health

system in planning their care abroad, creating breaks in the continuity of their care

trajectories and raising the possibility of encountering heightened health risks over the

course of their care. Both of these issues speak to the importance of developing and/or

improving the availability of high quality informational resources for medical tourists

considering going abroad for care.

Chapter 3 presented results of a thematic analysis from six focus groups

undertaken with Canadian family doctors. This analysis offered insights into how

primary care providers, largely neglected in the existing medical tourism literature, are

incorporated into supporting the planning and follow up stages of care provision for

medical tourists. The findings of this analysis spoke to the challenges medical tourism

poses to the existing role of Canadian family doctors. Family doctors were alarmed at

their exclusion from medical tourists’ planning, wanting to be at the very least aware of

patients’ intentions to travel outside of Canada for medical care. However, these desires

to be involved in their patients’ decision-making and planning for care abroad did not

extend to providing any assistance in research or information assessment, due primarily

to liability concerns. This desire to be involved, but to a poorly defined, limited degree,

indicated one source of tension that medical tourism raises for Canadian family doctors.

53

The findings further indicated that Canadian family doctors lack informational and

institutional supports with which they might confidently assist medical tourists in their

decision making. These supports are lacking both in regard to guiding family doctors

with best practices and in directing them to trustworthy information that they can direct

their patients to. It was suggested that this information-poor environment produces

friction between the inclinations of Canadian family doctors to support their patients, both

prior to and following care abroad, and their own professional liability concerns. This

friction compounds the uncertainty of individual Canadian family doctors as to what an

appropriate level of involvement should be. The findings from Chapter 3 provided further

rationale for the calls for the creation of neutral and accurate informational supports for

Canadian medical tourists by outlining the impacts this absence has on another

stakeholder group (Penney et al., 2011; Turner, 2011a).

Academic research on the phenomenon of medical tourism is in a nascent stage

(Hopkins et al., 2010; Johnston et al., 2010). As such, the existing literature abounds

with knowledge gaps in almost every conceivable area. Two broad knowledge gaps

informed my analyses presented in Chapters 2 and 3. Firstly, the bulk of the academic

literature deals with the macro- and meso-level implications of medical tourism at the

level of national health systems, regional economies, and individual hospitals (e.g.,

Blouin, 2007; Ormond, 2011; Ramirez de Arellano, 2007; Turner 2007a). This level of

focus largely neglects the experiences of medical tourists themselves (Crooks et al.,

2010). At the outset of this study, only Kangas (2002; 2007), Ehrbeck et al. (2008), and

Al-Sharif et al. (2010) had provided grounded, empirical evidence at the micro-level that

highlighted the experiences of medical tourists themselves. Major limitations existed

with all of these accounts, either due to their limited relevance to North-South / North-

North flows of medical tourists (e.g., Kangas, 2002 & 2007; Al-Sharif et al., 2010), or due

to methodological constraints that produced an overly ‘rough grained’ resolution of

results (e.g., Ehrbeck et al., 2008, Al-Sharif et al., 2010). This absence of a ‘fine

grained’ engagement with medical tourists from the Global North, in a manner that offers

a detailed understanding of their experiences, provided the rationale for the research

found in Chapter 2. Like Chapter 2, Chapter 3 was informed by the relative absence of

fine-grained accounts of medical tourism, but worked to address the lack of engagement

with the domestic health systems of medical tourists. While physicians have written on

54

their experiences with medical tourists returning to their home health systems (e.g.,

Birch et al., 2010, Cheung & Wilson, 2008), these have been from the perspectives of

surgeons addressing complications, not of primary care providers who have ongoing

relationships with patients.

4.2. Revisiting Objectives

In this section, I revisit the objectives of my thesis research. I then explore the

themes and issues that are present in both Chapters 2 and 3, as these serve to unite the

thesis as a whole. By speaking to both medical tourists and family doctors

independently of one another about the same phenomenon, these analyses provided the

opportunity to examine where accounts converge and diverge from one another. This

composite analysis creates a more accurate and coherent understanding of the

phenomenon of outbound medical tourism from Canada than if either stakeholder group

was consulted alone.

4.2.1. Reported Engagement between Canadian Family Doctors and Outbound Medical Tourists

With regard to the first objective of my thesis, documenting how Canadian family

doctors are involved in the care of outbound medical tourists, Chapters 2 and 3

demonstrate that there is considerable overlap between the experiences of these two

groups and little divergence. Perhaps most importantly, both medical tourists and family

doctors reported limited to no meaningful engagement with one another prior to or

following a medical tour as a common circumstance. The lack of concern expressed by

medical tourists at this degree of engagement is contrasted by the significant concerns

raised by family doctors at the current state of interaction between these two groups.

When the medical tourists reported on in Chapter 2 included their family doctors

in their course of care abroad, it was almost never in a consultative capacity to assess

the benefits and risks of seeking care abroad. Participants sought assistance from their

family doctors only to gain access to their medical records or to diagnostic testing

requested by the out-of-country physician in order to assist their care abroad. This

assistance was typically sought by medical tourists only after their having firmly decided

55

to travel for care. It is notable that this pursuit of diagnostic testing was independently

raised multiple times by family doctors as a source of possible tension around a medical

tour. Across four of the six focus groups, some family doctors expressed concern that

supporting medical tours abroad through publicly insured means such as referral for

diagnostic testing is a misuse of public resources. This tension highlights one of the

challenges posed to the traditional values and arrangement of the Canadian system by

the patient-consumer framework that informs medical tourism, where medical care is

perceived as a commodity available on demand and driven by patient desires (Ormond,

2011; Turner, 2007a). The values of solidarity and universality that underpin the

Canadian system are maintained and put into practice, in part, by the actions and

decisions of individual physicians that evaluate the necessity and urgency of care. The

realization of these values is directly challenged by the consumer framework of medical

care that medical tourists adopt when enlisting their family physicians support. As

demonstrated by the behaviour of medical tourists in pursuing diagnostic testing through

their family doctors, the Canadian system is capable of supporting the patient-consumer

framework necessitated by medical tourism to a limited degree, but strains may emerge

in patient-physician relationships when the perceptions of these groups regarding the

necessity and quality of privately purchased surgery abroad do not align. This potential

for strain requires a more coherent articulation of the responsibilities of each group

toward one another.

The accounts of limited engagement between medical tourists and their family

doctors presented in Chapter 2 were consistent with those of the family doctors in

Chapter 3, reflecting a high degree of confirmation between the datasets. Family

doctors reported being either over- or under-engaged by medical tourists, and rarely felt

they achieved a productive middle ground with this patient group. When asked why they

thought they were not being consulted prior to medical tourists’ trips, family doctors

suggested it was either because medical tourists believed their family doctor would be of

little assistance to them, or that patients felt uncomfortable raising the issue of medical

tourism due to concerns that it might negatively impact their long term relationship. Both

rationales were indeed reported by the medical tourist interviewees, with the former

being most common. This widespread lack of confidence in the knowledge and outlook

of family doctors by medical tourists discussed in Chapter 2 and confirmed by the family

56

doctors in Chapter 3 speaks to the necessity of improving the standard of care available

to this group of patients. This could be achieved by better educating family doctors on

how to best support patients considering leaving the country for medical care as well as

by informing medical tourists of the importance of making family doctors aware of their

medical care abroad so that they can assist in supporting them. Clarifying the

appropriate roles and responsibilities of both groups might also help reduce the

likelihood of any conflicts or ethical tensions emerging between family doctors and their

patients.

4.2.2. Desired Engagement between Canadian Family Doctors and Outbound Medical Tourists

The current mode of engagement between patients and family doctors that was

most commonly described by participants in Chapters 2 and 3 indicate that there is a

great deal of room for improvement in the interactions between these groups. Such

improvement is chiefly centered on two domains; (1) communication between family

doctors and medical tourists prior to and returning from receiving care abroad, and (2)

the quality of information and support available to each group. The medical tourists

discussed in Chapter 2 rarely incorporated their family doctors in their course of care

abroad and were undisturbed by this lack of involvement. Given the concerns

expressed both by the family doctors in Chapter 3 and in the wider medical tourism

literature (Burkett, 2008; Crooks et al., 2010; Lunt & Carrera, 2010), medical tourists’

lack of concern is likely informed, at least in part, by a lack of knowledge of the

heightened health and safety risks they face both domestically and abroad when

engaging in medical tourism. This lack of concern makes it difficult to determine medical

tourists’ desired degree of engagement with their family doctors, and necessarily results

in a greater focus in this sub-section on the views expressed by family doctors in

Chapter 3.

The findings of Chapters 2 and 3 suggested that improving communication

between family doctors and medical tourists, as a form of desired engagement, can be

achieved primarily through increasing the likelihood and frequency of contact between

them prior to and following care abroad. The family doctors made it clear that

communication between these groups should be made the rule, not the exception, and

57

that they want to play a supportive role towards patients. Furthermore, Chapter 3

provided evidence that family doctors wish to be engaged in both the planning and

follow-up stages of a medical tour, but are aware that they are under-utilized in this

regard. The kinds of interactions they wish to have, however, are strictly bounded by

liability concerns; thus, Canadian family doctors desired being made aware of their

patients’ intents to travel, broadly gauging these patients’ outlook and expectations, and

if possible, ‘course correcting’ their navigation of the domestic health system, but did not

want involvement in destination selection or thoroughly assessing the quality of their

patients’ research. Related to this, family doctors wanted to be able to refer patients to

trusted third party materials that could help them assess the risks of traveling for care

more effectively.

With regard family doctors’ desires to improve the quality of information between

them and medical tourists, medical tourists commonly saw no need to provide their

family doctors with medical records from their treatment abroad although they often

returned home with them in hand. Family doctors in Chapter 3 echoed the rarity of being

provided records by medical tourists upon return home. This challenge to integrated

medical record keeping raises concerns about the continuity of care that Canadian

family doctors can provide medical tourists immediately upon return and into the long-

term future. Interestingly, despite their desires to have access to such records, family

doctors also raised concerns about the usefulness of international medical care records,

citing language and differing record-keeping methods as barriers to their interpretation.

Even having acknowledged this, family doctors did want to incorporate the medical

records from abroad into their patients’ histories. The fact that Canadian medical

tourists often do return home with these records and Canadian family doctors desire

access to them suggests that this is a key nexus for improving the quality of information

exchange between them. Should the frequency of pre-trip engagement between these

groups improve, developing a clear plan that outlines how to effectively collect and

integrate a patient’s medical records upon returning to Canada is a relatively simple and

effective responsibility that could be assumed by both parties in consultation with one

another.

58

4.2.3. Supporting Canadian Family Doctors and Outbound Medical Tourists

In reflecting on the third objective of my thesis, which is to identify the current

quality and kinds of support available to Canadians and family doctors regarding medical

tourism, it became clear from speaking with these stakeholders that both groups lack

access to high quality informational supports. Given the recent and relatively short

period in which medical tourism has grown in popularity, the lack of reliable informational

supports for both of these groups is unsurprising. The absence of informational supports

for either group presents an opportunity for coordination between the resources that

could be made available to stakeholders, in terms of content, modes of delivery, and

consistency of messaging. This said, each group requires a different form of

informational support. For Canadian family doctors, professional guidelines must be

developed and disseminated to provide a more consistent standard of care that protects

them from liability, while prospective Canadian medical tourists require high quality,

neutral information to more accurately inform them of risks and benefits of privately

purchasing surgery abroad in addition to encouraging them to incorporate their family

doctors into their courses of care. These supports are needed in order to make the shift

from the now common limited involvement between medical tourists and family doctors

to the desired engagements aimed at mitigating the risks faced by Canadian medical

tourists both within and outside of the Canadian health system.

Professional guidelines were expressed as desirable informational support by

participants from Chapter 3, as they would assist them in more clearly interpreting their

professional responsibilities towards medical tourists. Lacking a professional standard

for the depth and kinds of responsibilities deemed suitable likely contributes to some of

the inconsistency in the roles and responsibilities adopted by family doctors towards

medical tourists that were reported in both Chapters 2 and 3. This lack of

standardization also serves as a barrier to achieving the degree and quality of

engagement with medical tourists prior to travel (if not even booking) desired by family

doctors. The lack of reliable informational supports for medical tourists available to

family doctors negatively impacts their abilities to achieve their desired kinds of

engagement with medical tourists by leaving them with no resources to refer these

patients towards. From the perspective of medical tourists interviewed for Chapter 2,

59

this lack of capacity amongst family doctors may contribute to Canadian medical tourists’

limited regard for the current usefulness of family doctors in their course of care abroad.

4.3. Remaining Knowledge Gaps and Future Research Directions

A number of knowledge gaps related to this thesis remain. Perhaps most

significantly, there is no surveillance or tracking of Canadian medical tourists (Eggerston,

2006; Snyder et al., 2010; Turner, 2007b). While precise figures are lacking, it is known

that, at a minimum, thousands of Canadians are exiting the country for medical care

every year (Johnston et al., 2011). This bolsters the relevance of calls made here and

elsewhere for the development of better supports for this patient group. However, the

lack of fine-grained accounting to capture patient flows leaving or returning to Canada

makes accurate assessments of the impacts of medical tourism on provincial health

systems impossible. Quantitative research into Canadian medical tourism would assist

in both targeting interventions towards regions experiencing high outflows of medical

tourists, in which family practices would be a key intervention site, and in helping to

communicate the urgency or relevance of this thesis research to a wider audience.

A knowledge gap that became evident over the course of my analyses pertains

to how ‘the Internet’ was employed by the medical tourists who participated in the study.

When participants spoke of using the Internet to gather information on care abroad, they

rarely could remember in detail the kinds of websites they accessed. Furthermore, I

neglected to have them comment in detail on how they assessed the reliability of these

websites and the information on them, leading to unanswered questions of what kinds of

specific online information were considered to be the most important or relevant in their

decision-making processes. Future studies examining the experiences of medical

tourists would benefit from employing a focused set of questions to capture what kinds of

online information bolster the confidence of prospective medical tourists to understand

the decision-making processes in greater detail.

The relevance of my thesis research beyond Canada could be confirmed or

disrupted by future research examining the experiences of medical tourists from different

60

countries, especially regarding their engagement with their primary care providers. The

only medical association to have yet issued guidelines to their members to assist them in

supporting medical tourists is the American Medical Association (Caffarini, 2008). It

would be useful to know if these (limited) guidelines improve the quality of care and

degree of support they are able to provide to their patients due to potentially clearer

understandings of where their professional roles and responsibilities begin and end.

Similarly, it would be helpful to know if the findings of the focus groups held with family

doctors in British Columbia hold true elsewhere in Canada. Family doctors in other

provinces may be exposed to differing numbers of medical tourists due to varying

regional popularity. As a consequence, family doctors in other regions may be more or

less equipped to support this patient group. Knowing the variability of attitudes and

experiences of primary care providers across Canada may also improve the relevance

and quality of guidelines that might be created by a national organization for this

stakeholder group.

This thesis holds particular relevance to future research conducted by health

geographers. Most broadly speaking, medical tourism is a spatial phenomenon well

suited to geographic inquiry, of which this thesis represents an early, focused example.

As health systems continue to evolve within larger and increasingly dense networks of

communication and transportation, the traditional regional, provincial, and national

scales at which health systems have been conceived of and operated at will likely

change both subtly and drastically. These traditional scales of operation may

conceivably be joined by the wider emergence of international health services over the

same period in which their boundaries erode and intermingle with one another. Health

geographers are well situated to conceptualize and investigate potential pathways for

these developments in the hopes that better documenting and understanding them will

allow them to develop in as equitable and widely accessible fashion possible.

4.4. Overall Limitations

In Chapters 2 and 3 I have identified limitations specific to the analyses

presented in each. There are some limitations to also acknowledge in the thesis as a

whole. It was common for family doctors to report that they were unaware of when their

61

patients had traveled for care. It was most often the case that family doctors became

aware of medical tourists in their practices when they came across unexplained surgical

scars during physical examinations or in cases where their patients consulted with them

after developing complications from a procedure abroad. This is consistent with the

accounts provided by medical tourists and raises a key limitation. Many of the concerns

raised by the family doctors were informed by the sample of medical tourists they were

exposed to, which likely heavily consisted of those experiencing (often severe)

complications. These outlier experiences may have coloured the perceptions of many of

our participants and the kinds of issues they raised in the questions asked of them.

Related to the above limitation, I was unable to recruit any more than four

medical tourists who experienced complications as a result of their surgeries abroad.

Because of the lack of reliable statistics on medical tourism and medical tourists there is

no way of knowing whether this group was under- or over-represented in the sample. At

the same time, my research has not sought representativeness, so this is not an issue

per se. Of those participants that did experience complications, none regretted their

pursuit of care abroad. What is lacking in my thesis are the voices of patients who have

had significant complications following surgery abroad to the point that they have

become outspoken critics of the industry. These individuals exist, and are simply not

represented in my thesis. This reality may have limited uncovering further knowledge

gaps, especially from the perspectives of Canadian medical tourists who experienced

serious complications and sought supportive care from their family doctors.

4.5. Conclusion

While the lack of surveillance makes quantitative projections of the future flows of

Canadian medical tourists a rash effort, the underlying pressures pushing Canadians to

seek care abroad give no signs of drastic change, while at the same time the pull factors

associated with the medical tourism industry continue to expand (Connell, 2011;

Philippon & Braithwaite; Purdy & Lam, 2011; 2008). Consequently, the phenomenon of

outbound medical tourism from Canada is unlikely to diminish in coming years, and is

more likely to increase in popularity as word-of-mouth networks between prospective

patients normalize and advertise the notion (if not even acceptability and tolerance) of

62

accessing medical care abroad. Given the likelihood of these latter trends, there are

clear and pressing reasons to improve the quality of supports available to this patient

group. This must be done in order to help mitigate the unique risks they face when

exiting their provincial and territorial health systems, such as interrupted continuity of

care, uncertain quality of informed consent, and poorly documented medical

complications. This thesis provided evidence that informs this call for improved support

for Canadian medical tourists to help ensure their safety and well-being.

Ultimately, the evaluation of future interventions aimed at having medical tourists

engage with their family doctors must be measured by their success in reducing the risks

faced by these patients while supporting family doctors to practice confidently, free from

uncertainty about liability or physician overreach. As Canadian family doctors are ideally

the first point of contact between Canadians and their health system (Chan, 2003;

Romanow, 2002), I believe they are an important group to target in crafting better

supports for Canadian medical tourists and have asserted this in my thesis. While

supports in and of themselves, family doctors are also in need of access to professional

guidance in the forms of guidelines for themselves and informational resources for their

patients in order to perform their desired roles.

A key message that cross-cuts the findings of my analyses is that: interventions

designed to improve the domestic support available to Canadian medical tourists must

simultaneously work to alter their care-seeking behaviours in order to increase the

frequency of engagement with family doctors, produce informational supports for family

doctors and patients alike, and ultimately improve the quality of engagement between

these groups by clearly demarcating roles and responsibilities for each. Failing to

implement interventions in any of these areas, while proceeding in others, will likely

result in a continued mismatch between the supports available to Canadian medical

tourists and these patients’ informational needs, along with those of their family doctors.

At the same time, such a mismatch will ultimately result in failure to decrease the novel

health risks medical tourists currently face and increase family doctors’ comfort levels in

meaningfully engaging with these patients within the bounds of their professional

practice.

63

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